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Understanding ICD-9-CM Coding: A Worktext, Third Edition Mary Jo Bowie and Regina M. Schaffer Vice President, Career and Professional Editorial: Dave Garza Director of Learning Solutions: Matthew Kane Executive Acquisitions Editor: Rhonda Dearborn

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SECTION

I

Introduction to Coding

1: Introduction to Coding and Coding Professions, 3

4: ICD-9-CM Coding Conventions and Steps in Coding, 43

2: An Overview of ICD-9-CM, 12

5: Coding Guidelines, 59

3: ICD-9-CM Volume Organization, 28

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Introduction to Coding and Coding Professions

CHAPT ER

1

Chapter Outline Introduction Professional Coding History of ICD-9-CM Coding Health Insurance Portability and Accountability Act of 1996 Transitioning to ICD-10-CM and ICD-10-PCS

Professional Coding Associations Employment Opportunities for Coders Abbreviations Internet Links Summary Chapter Review

Objectives At 1. 2. 3. 4. 5.

the conclusion of this chapter, the student will be able to: Describe the purpose of ICD-9-CM coding. Explain the development of the ICD classification system. Identify professional coding certifications and organizations. Discuss the standards mandated by the Health Insurance Portability and Accountability Act. Outline the transition to ICD-10-CM and ICD-10-PCS.

Key Terms Accrediting Bureau of Health Education Schools (ABHES) Administrative Simplification American Academy of Professional Coders (AAPC) American Association of Medical Assistants (AAMA) American Health Information Management Association (AHIMA)

American Medical Technologists (AMT) Centers for Medicare and Medicaid Services (CMS) Certified Coding Associate (CCA) Certified Coding Specialist (CCS) Certified Coding Specialist, PhysicianBased (CCS-P) Certified Health Data Analyst

Certified in Healthcare Privacy and Security (CHPS) Certified Medical Assistant (CMA) Certified Professional Coder (CPC) Certified Professional Coder, Hospital-Based (CPC-H) Centers for Medicare and Medicaid Services (CMS) Coding

Commission on Accreditation of Allied Health Education Programs (CAAHEP) Health Insurance Portability and Accountability Act of 1996 (HIPAA) ICD-8 International Classification of Diseases, Ninth Revision (ICD-9)

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Section I

Introduction to Coding

International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) Morbidity

Mortality National Center for Health Statistics (NCHS) Public Law 104-191

Registered Health Information Administrator (RHIA) Registered Health Information Technician (RHIT)

Registered Medical Assistant (RMA) World Health Organization (WHO)

Introduction Medical coding is the assignment of numerical or alpha-numerical digits and characters to specific diagnostic and procedural phrases. This coding, like any other language, needs to be translated to be understood, and each combination of numbers or of numbers and letters represents a diagnostic or procedural phrase. EXAMPLE: The diagnostic phrase “appendicitis” is translated into diagnostic code 540.9. The procedural phrase “appendectomy” is translated into procedure code 47.09. By using ICD-9-CM codes, healthcare professionals can collect, process, and analyze diagnostic and procedural information more effectively.

Professional Coding Coding is the language used by insurance companies and healthcare providers to tell a story about what brought a person to a facility for treatment and what services were performed. The ability to communicate and translate these codes to another party is vital to the care and treatment rendered to the patient. These codes are also communicated to the insurance company, which is required to make payment on the patient’s visit. It is critical that the coding language is fully understood and “spoken” fluently by all the necessary parties so that the essence of the patient’s visit and treatment can be conveyed. In the chapters that follow, the student will gain a greater knowledge of the language of coding, specifically ICD-9-CM. By the completion of this book, the student will have the knowledge base needed to begin “speaking” the language of ICD-9-CM coding, which has increasingly become a tool used in the healthcare industry.

History of ICD-9-CM Coding ICD-9-CM, an abbreviation for the International Classification of Diseases, Ninth Revision, Clinical Modification, is an arrangement of classes or groups of diagnoses and procedures by systematic division. ICD-9-CM is based on the official version of the International Classification of Diseases, Ninth Revision (ICD-9), which was developed by the World Health Organization (WHO) in Geneva, Switzerland. The WHO assumed responsibility in 1948 for preparing and publishing the revisions to ICD every 10 years. Thus, with every 10-year revision, the name of the current ICD changes. For example, ICD-8 was revised to ICD-9. The ICD classification system was designed to compile and present statistical data on morbidity, the rate or frequency of disease, and mortality, the rate or frequency of deaths. This form of classification was first used by hospitals to track, store, and retrieve statistical information. However, a more efficient basis for storage and retrieval of diagnostic data was needed. In 1950, the Veterans Administration and the U.S. Public Health Service began independent studies of using the ICD for hospital indexing purposes. By 1956, the American Hospital Association and the American

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Association of Medical Record Librarians, now the American Health Information Management Association, felt that the ICD form of classification provided an efficient and useful venue for indexing hospital records. With hospital indexing in mind, the WHO international conference made its eighth revision to the ICD in 1966. Some countries found that ICD-8 lacked the detail needed for diagnostic indexing. In the United States, consultants were asked to study ICD-8 for its applicability to various users. The Advisory Committee to the Central Office on ICD published the International Classification of Diseases, Eighth Revision, adapted for use in the United States in 1968. It became known as ICDA-8 and was used for coding diagnostic data for both morbidity and mortality statistics in the United States. In 1979, ICD-9-CM replaced earlier, less specific versions of the classification system. The ICD-9-CM streamlined the other versions of the ICD classification system into a single classification system and was intended for use primarily in hospitals in the United States. The ICD-9-CM provides a more complete classification system for morbidity data to be used for indexing and reviewing patient records and medical care. Within the United States, two agencies are responsible for the annual updates to the ICD-9-CM codes. The National Center for Health Statistics (NCHS) is responsible for maintaining the diagnostic codes that are maintained in volumes 1 and 2 of ICD-9-CM. The Centers for Medicare and Medicaid Services (CMS) is responsible for maintaining the procedure codes of ICD-9-CM, which are found in volume 3. Since the clinical modifications have been developed, IDC-9-CM has been used to code patient encounters throughout the U.S. healthcare system. The Medicare Catastrophic Coverage Act of 1988 mandated the reporting of ICD-9-CM diagnostic codes on all claims submitted to the Medicare program. In subsequent years private insurance companies required ICD-9-CM codes to be submitted. ICD-9-CM provides a coding system that reflects the signs, symptoms, disorders, diseases, examinations, or other reasons for the services billed by a provider for payment, giving the payer a clear picture of the reason for the patient visit. ICD-9-CM coding is the key storyteller to the insurance companies, explaining what brought the patient into the office or facility (by use of a diagnostic code), as well as what services were facility provided (by use of a procedural code). Because coding plays such a critical role in reimbursement for service rendered, correct coding practices are essential.

Health Insurance Portability and Accountability Act of 1996 The Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104-191, was passed by Congress to improve the portability and continuity of healthcare coverage. The Administrative Simplification aspect of this legislation developed standards for the electronic exchange of healthcare data by administrative and financial transactions. The final rule on transactions and code sets mandated the use of standardized code sets for the electronic submission of healthcare data. ICD-9-CM diagnostic codes are reported for diagnoses for all levels of care, including all hospital services, clinic services, long-term care, and physician offices. ICD-9-CM procedural codes are reported for inpatient hospital services. Healthcare providers must now use ICD-9-CM codes to accurately report diagnoses and services provided on submitted insurance claims. The codes are used to determine not only payment but also the medical necessity of care, which is defined by Medicare as “the determination that a service or procedure rendered is reasonable and necessary for the diagnosis or treatment of an illness or injury.” Thus, coders perform a vital role in the healthcare system.

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Section I

Introduction to Coding

Transitioning to ICD-10-CM and ICD-10-PCS On August 22, 2008, the U.S. Department of Health and Human Services (HHS) published a proposed rule to adopt ICD-10-CM and ICD-10-PCS to replace ICD-9-CM. On January 16, 2009, the final rule on adoption of ICD-10-CM and ICD-10-PCS was published with an implementation date of October 1, 2013. When compared to ICD-9-CM, ICD-10-CM and ICD-10-PCS are more comprehensive coding systems. ICD-10-CM contains approximately 68,000 diagnostic codes, compared to the 14,000 diagnostic codes in ICD-9-CM. ICD-10-PCS contains slightly over 72,500 procedural codes, compared to only 3,800 in ICD9-CM. Between now and 2013, the healthcare industry will be preparing to transition to the new, expanded coding system, which will allow for more complete and comprehensive coding and reporting of diagnostic and procedural information. For comprehensive coverage of ICD-10-CM and ICD-10-PCS, refer to Delmar Cengage Learning’s Understanding ICD-10-CM and ICD-10-PCS by Mary Jo Bowie and Regina Schaffer.

Professional Coding Associations In an effort to assist and promote correct coding and reimbursement, several organizations help educate, train, and credential coders. Credentialing helps to ensure the proper training and education of coders.

American Health Information Management Association (AHIMA) The American Health Information Management Association (AHIMA) represents health information professionals who manage, organize, process, and manipulate patient data. Health information professionals have knowledge of electronic and paper medical record systems as well as of coding, reimbursement, and research methodologies. The health information managed by these professionals directly impacts patient care and financial decisions made in the healthcare industry. Members of AHIMA feel that the quality of patient care is directly related to the effectiveness of the information available. Healthcare providers, insurance companies, and institutional administrators depend on the accuracy and quality of the health information available. For this reason, AHIMA members are trained to be able to provide a level of service that maintains the quality and accuracy of the medical information they come in contact with. AHIMA offers certifications and credentialing to ensure that its members meet the level of proficiency that is needed to provide educated professionals to manage healthcare information. The members receive these various certifications or credentials through a combination of education, experience, and performance on national certification exams.

The various certifications and credentials are listed below. CCA

Certified Coding Associate

CCS

Certified Coding Specialist

CCS-P

Certified Coding Specialist, Physician-Based

CHPS

Certified in Healthcare Privacy and Security

RHIA

Registered Health Information Administrator

RHIT

Registered Health Information Technician

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Continuing education credits are required to maintain the certifications once they have been received. These continuing education credits can be obtained through various conferences, seminars, classes, or other avenues of career development that AHIMA publishes and makes available to its members.

American Academy of Professional Coders (AAPC) The American Academy of Professional Coders (AAPC) was founded in an effort to elevate the standards of medical coding. The AAPC provides networking opportunities through local chapter memberships and conferences. It also provides ongoing educational opportunities for members. Similar to AHIMA, AAPC offers certifications for professional proficiency. The Certified Professional Coder (CPC) certification is available for coders in physician offices and clinics, and the Certified Professional Coder, Hospital-Based (CPC-H) is available for coders in the hospital setting. There are also two additional certifications for individuals who have not yet met the work experience requirements of the CPC and CPC-H certifications: the Certified Professional Coder Apprentice (CPC-A) and the Certified Professional Coder, Hospital Apprentice (CPC-H-A). Continuing education credits are also required on a biannual basis for the AAPC certification. Whereas AHIMA deals with all aspects of health information, AAPC focuses on coding and reimbursement.

American Association of Medical Assistants (AAMA) The American Association of Medical Assistants (AAMA) represents individuals trained in performing routine administrative and clinical jobs, including coding, that keep medical offices and clinics running efficiently and smoothly. Credentialing is voluntary in most states. A medical assistant is not required to be certified or registered. However, the AAMA offers the national credential of Certified Medical Assistant (CMA) certification for the medical assisting profession. The Commission on Accreditation of Allied Health Education Programs (CAAHEP) collaborates with the Curriculum Review Board of the AAMA Endowment to accredit medical assisting programs in both public and private postsecondary institutions throughout the United States. This prepares candidates for entry in the medical assisting field. Students who have graduated from a medical assisting program accredited by the CAAHEP or the Accrediting Bureau of Health Education Schools (ABHES) are eligible to take the CMA examination, which tests candidates on tasks that are performed in the workplace. Recertification is required every five years, either by continuing education or by examination.

American Medical Technologists (AMT) The American Medical Technologists (AMT) offers professional credentials such as Registered Medical Assistant (RMA). These professionals perform the same tasks as those of a CMA but are credentialed by AMT. Students who have completed a college-level program approved by the U.S. Department of Education may voluntarily take the examination that would credential them as an RMA.

Employment Opportunities for Coders Regardless of the credentialing path that an individual takes, career opportunities are numerous. Coders work in all aspects of health care, including hospitals, physician offices, clinics, long-term care facilities, insurance companies, and billing agencies. With the evolution of the electronic health record, more coders will be needed to review the information that is generated for its accuracy and compliance. The Bureau of Labor Statistics calculates that the growth of coding jobs in the United States will grow faster than will the average of all occupations through 2010. As the population of the United States ages, more individuals will use healthcare services at a greater rate, thus increasing the need for additional services and for coded healthcare data.

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Section I

Introduction to Coding

Abbreviations AAPC

American Academy of Professional Coders

AHIMA

American Health Information Management Association

APC

Ambulatory Payment Classification

ASC

Ambulatory Surgery Center

CCA

Certified Coding Associate

CCI

Correct Coding Initiative

CCS

Certified Coding Specialist

CCS-P

Certified Coding Specialist – Physician

CMS

Center for Medicaid and Medicare Services

CMT

Certified Medical Transcriptionist

CPC

Certified Professional Coder

CPC-H

Certified Professional Coder, Hospital-Based

DRG

Diagnosis Related Groups

ED

Emergency Department

EOB

Explanation of Benefits

HIM

Health Information Management

HIPAA

Health Insurance Portability and Accountability Act

HIT

Health Information Technology

ICD-9-CM

International Classification of Diseases—Ninth Edition, Clinical Modification

IP

Inpatient

PPS

Prospective Payment System

RHIA

Registered Health Information Administrator

RHIT

Registered Health Information Technician

UACDS

Uniform Ambulatory Care Data Set

UHDDS

Uniform Hospital Discharge Data Set

Internet Links To obtain ICD-9-CM updates through a free download, visit http://www.cdc.gov/nchs/icd9.htm. To order a CD-ROM that contains the complete version of ICD-9-CM, see http://bookstore.gpo.gov. (This CD-ROM can also be ordered from Superintendent of Documents, U.S. Government Printing Office: 888-293-6498 or 866-512-1800; fax, 202-512-2250. Commercial publishing companies also sell ICD-9-CM books.) To obtain information on the AAMA, visit www.aama-ntl.org. To obtain information on the AAPC, visit www.aapc.com.

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9

Introduction to Coding and Coding Professions

To obtain information on the AHIMA, visit www.ahima.org. To obtain information on AMT, visit www.amt1.com. To obtain information on career statistics and opportunities, visit the Bureau of Labor Statistics at www.bls.gov.

Summary • Coding is the assignment of numerical or alpha-numeric digits and characters to diagnostic and procedural phrases. • ICD-9-CM coding is used in the United States to code diagnoses and procedures. • The National Center for Health Statistics coordinates the modifications of the disease classification. • The Centers for Medicare and Medicaid Services coordinates the procedural classification updates. • The American Health Information Management Association offers the following credentials: Certified Coding Associate; Certified Coding Specialist; Certified Coding Specialist, PhysicianBased; Certified in Healthcare Privacy; Certified in Healthcare Security; Certified in Healthcare Privacy and Security; Registered Health Information Administrator; and Registered Health Information Technician. • The American Academy of Professional Coders offers the following credentials: Certified Professional Coder; Certified Professional Coder, Hospital-Based; Certified Professional Coder Apprentice; and Certified Professional Coder, Hospital Apprentice. • The American Association of Medical Assistants offers the Certified Medical Assistant credential. • The American Medical Technologists offers professional credentials such as a Registered Medical Assistant. • The Administrative Simplification aspect of Health Insurance Portability and Accountability Act of 1996 developed standards for the electronic exchange of healthcare data for administrative and financial transactions.

Chapter Review True/False: Indicate whether each statement is true (T) or false (F). 1.

The CPC credential is offered by the American Health Information Management Association.

2.

AHIMA requires credentialed professionals to obtain continuing education credits to maintain their credentials.

3.

CMAs must be licensed to practice in the United States.

4.

The final rule on transactions and code sets mandated the use of ICD-9-CM for the electronic submission of healthcare data.

5.

The Centers for Medicare and Medicaid Services coordinates the procedural classification updates.

Fill-in-the-Blank: Enter the appropriate term(s) to complete each statement. .

6. The rate or frequency of diseases is known as 7. ICD-9 was developed by the

.

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Section I

Introduction to Coding

8. ICD-9-CM is an abbreviation for the International Classification of Diseases, Ninth Revision, . .

9. Modifications of the ICD-9-CM disease classification is coordinated by 10. Public Law 104-191, known as Congress to improve the portability and continuity of health care coverage.

, was passed by

Short Answer: Define each abbreviation and acronym listed. 11. AHIMA

12. RHIA

13. CPC-H

14. AMT

15. CPC

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11

16. AAMA

17. RMA

18. CMA

19. CCS

20. CCS-P

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CHA PTER

2

An Overview of ICD-9-CM

Chapter Outline Introduction ICD-9-CM Coding Book Format Volume 1—Chapters of the Classification of Diseases and Injuries Volume 1—Supplementary Classifications Volume 1—Appendices

Volume 2—Alphabetic Index Volume 3—Tabular List and Alphabetic Index of Procedures Internet Links Summary Chapter Review

Objectives At 1. 2. 3. 4. 5. 6.

the conclusion of this chapter, the student will be able to: Explain the format ICD-9-CM Coding Book. Identify the chapters of volume 1, Tabular List of Diseases and Injuries. List the appendices of volume 1. Discuss the purpose of V codes and E codes. Explain the organization of volume 2, Alphabetic Index. Describe the format of volume 3, Tabular List and Alphabetic Index of Procedures.

Key Terms Alphabetic Index Alphabetic Index to External Causes of Injury and Poisoning Alphabetic Index to Poisoning and External Causes of Adverse Effects of

Drugs and Other Chemical Substances Anatomical Site Appendices Appendix A— Morphology of Neoplasms

Appendix C— Classification of Drugs by American Hospital Formulary Service List Number and Their ICD-9-CM Equivalents Appendix D— Classification of Industrial Accidents According to Agency

Appendix E—List of Three-Digit Categories Classification of Diseases and Injuries Congenital Anomaly E Code

Reminder As you work through this chapter, you will need to have a copy of the ICD-9-CM coding book to reference.

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Etiology Index to Diseases and Injuries Perinatal Period Supplementary Classification of

External Causes of Injury and Poisoning Supplementary Classification of Factors Influencing Health Status and

An Overview of ICD-9-CM

Contact with Health Services Supplementary Classifications Table of Drugs and Chemicals

13

Tabular List and Alphabetic Index of Procedures Tabular List of Diseases and Injuries V Code

Introduction The ICD-9-CM coding system allows healthcare providers and healthcare facilities to answer the question “what brought the patient to my office/facility?” This information is needed for statistical purposes, reimbursement, and continuity of patient care. To accurately convey this information, the coder must become familiar with all aspects of the ICD-9-CM coding book. Within this chapter an overview of ICD-9-CM will be presented.

ICD-9-CM Coding Book Format The ICD-9-CM coding book consists of three volumes. Volume 1 is the Tabular List of Diseases and Injuries, a numerical listing of diseases and injuries found in ICD-9-CM. Each chapter of this volume is subdivided into sections, categories, and subcategories. The specific organization of volume 1 will be discussed in Chapter 3 of this textbook. (The Tabular List of Diseases and Injuries is most commonly referred to as the “Tabular.”) Volume 2 of the ICD-9-CM, known as the Alphabetic Index, is an alphabetic listing of the codes found in volume 1 and is essential for accurate coding. (The Alphabetic Index is most commonly referred to as the “Index.”) The three sections of the index include: • Index to Diseases and Injuries • Alphabetic Index to Poisoning and External Cause of Adverse Effects of Drugs and Other Chemical Substances • Alphabetic Index to External Causes of Injury and Poisoning (E codes) Volume 3 is the Tabular List and Alphabetic Index of Procedures and is used in a facility setting, not routinely in an office or outpatient setting. This particular volume contains both a tabular listing and an alphabetic listing of procedures and surgeries. The format for volume 3 is the same as in volumes 1 and 2 except that procedure codes consist of two digits followed by a decimal point and then one or two additional digits. EXAMPLE: Diagnostic Code Description

Diagnostic Code

Procedural Code Description

Procedural Code

Acute appendicitis without mention of peritonitis

540.9

Laparoscopic appendectomy

47.01

Cholelithiais with obstruction

574.21

Cholecystectomy

51.22

Volume 1—Tabular List of Diseases and Injuries. Volume 1, known as the Tabular List of Diseases and Injuries, is a tabular listing of disease and injuries that has three major subdivisions: • Classification of Diseases and Injuries • Supplementary Classifications (V codes and E codes) • Appendices

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Section I

Introduction to Coding

The first subdivision consists of the Classification of Diseases and Injuries, a numerical listing of diseases and injuries found in ICD-9-CM and consists of 17 chapters. These diagnostic chapters are organized according to etiology, the cause of disease, or anatomical site, the body system involved. EXAMPLE: Refer to the information in the following list. Chapter 2, “Neoplasms,” is an example of a chapter organized according to etiology, and Chapter 12, “Diseases of the Skin and Subcutaneous Tissue,” is a chapter organized by anatomical site. Chapter Titles of the Classification of Diseases and Injuries 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17.

Infectious and Parasitic Diseases Neoplasms Endocrine, Nutritional, and Metabolic Diseases and Immunity Disorders Diseases of the Blood and Blood-Forming Organs Mental Disorders Diseases of the Nervous System and Sense Organs Diseases of the Circulatory System Diseases of the Respiratory System Diseases of the Digestive System Diseases of the Genitourinary System Complications of Pregnancy, Childbirth, and the Puerperium Diseases of the Skin and Subcutaneous Tissue Diseases of the Musculoskeletal System and Connective Tissue Congenital Anomalies Certain Conditions Originating in the Perinatal Period Symptoms, Signs, and Ill-Defined Conditions Injury and Poisoning

Exercise 2–1

Identifying Chapters

For each chapter title, indicate whether the chapter is organized by etiology or by anatomical site. Chapter Title

Organization

1. Congenital Anomalies 2. Diseases of the Circulatory System 3. Diseases of the Digestive System 4. Endocrine, Nutritional, and Metabolic Diseases and Immunity Disorders 5. Infectious and Parasitic Diseases 6. Diseases of Skin and Subcutaneous Tissue 7. Mental Disorders 8. Diseases of Nervous System 9. Diseases of Genitourinary System 10. Diseases of Respiratory System

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An Overview of ICD-9-CM

15

Volume 1—Chapters of the Classification of Diseases and Injuries The Classification of Diseases and Injuries of volume 1 contains the following 17 chapters.

Chapter 1—Infectious and Parasitic Diseases (Code Range 001–139) This chapter includes diseases generally recognized as communicable or transmissible, as well as a few diseases of unknown but possibly infectious origin. EXAMPLE: Using volume 1 of your ICD-9-CM book, locate the start of chapter 1. Here you will find the code listing for infectious and parasitic diseases. Reference the following codes to familiarize yourself with this chapter. Diagnostic Code

Diagnostic Description

050.9

Smallpox, unspecified

008.41

Staphylococcus

036.0

Meningococcal meningitis

102.3

Hyperkeratosis

112.82

Candidal otitis externa

Chapter 2—Neoplasms (Code Range 140–239) This chapter contains code assignments for malignant, benign, carcinoma in situ, and neoplasms of uncertain and unspecified behavior. EXAMPLE: Using volume 1 of your ICD-9-CM book, locate the start of chapter 2. Here you will find the code listing for neoplasms. Reference the following codes to familiarize yourself with this chapter. Diagnostic Code

Diagnostic Description

140.4

Malignant neoplasm of the lower lip, inner aspect

145.4

Malignant neoplasm of the uvula

210.0

Benign neoplasm of the lip

230.2

Carcinoma in situ of stomach

233.0

Carcinoma in situ of breast

Note that this chapter is divided into the following sections: • Malignant neoplasms (140–208) • Benign neoplasms (210–229) • Carcinoma in situ (230–234) • Uncertain behavior (235–238) • Unspecified behavior (239)

Chapter 3—Endocrine, Nutritional, and Metabolic Diseases and Immunity Disorders (Code Range 240–279) Disorders and diseases of the thyroid and other endocrine glands, nutritional deficiencies, metabolic disorders, and disorders of the immune mechanism and immunity deficiencies are contained within this chapter. Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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Section I

Introduction to Coding

EXAMPLE: Using volume 1 of your ICD-9-CM book, locate the start of chapter 3. Here you will find the code listing for diseases of the endocrine system, nutritional and metabolic diseases, and immunity disorders. Reference the following codes to familiarize yourself with this chapter. Diagnostic Code

Diagnostic Description

240.9

Goiter

244.2

Iodine hypothyroidism

251.2

Hypoglycemia, unspecified

257.0

Testicular hyperfunction

278.01

Morbid obesity

Chapter 4—Diseases of the Blood and Blood-Forming Organs (Code Range 280–289) Contained within this chapter are types of anemias, coagulation defects, hemorrhagic conditions, and diseases of the white blood cells and other components of the blood. Also contained within this chapter are some diseases of the spleen and lymphatic system. EXAMPLE: Using volume 1 of your ICD-9-CM book, locate the start of chapter 4. Here you will find the code listing for diseases of the blood and blood-forming organs. Reference the following codes to familiarize yourself with this chapter. Diagnostic Code

Diagnostic Description

280.9

Iron-deficiency anemia, unspecified

281.1

Other vitamin B12 deficiency anemia

282.60

Sickle-cell disease, unspecified

288.3

Eosinophilia

289.1

Chronic lymphadenitis

Chapter 5—Mental Disorders (Code Range 290–319) This chapter contains mental disorders, including psychotic, personality, neurotic, and nonpsychotic disorders. Chemical dependencies, such as alcoholism and drug dependence, are contained in this chapter, as well as mental retardation and developmental disorders. This chapter also contains psychopathic symptoms that are not part of an organic illness. EXAMPLE: Using volume 1 of your ICD-9-CM book, locate the start of chapter 5. Here you will find the code listing for mental disorders. Reference the following codes to familiarize yourself with this chapter. Diagnostic Code

Diagnostic Description

290.11

Presenile dementia with delirium

291.0

Alcohol withdrawal delirium

298.3

Acute paranoid reaction

301.3

Explosive personality disorder

317

Mild mental retardation

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Chapter 6—Diseases of the Nervous System and Sense Organs (Code Range 320–389) This chapter contains diseases of the central and peripheral nervous systems that include the brain, spinal cord, meninges, and nerves. Disorders of the eye, adnexa, ear, and mastoid process are also coded from this chapter. EXAMPLE: Using volume 1 of your ICD-9CM book, locate the start of chapter 6. Here you will find the code listing for diseases of the nervous system and sense organs. Reference the following codes to familiarize yourself with this chapter. Diagnostic Code

Diagnostic Description

320.2

Streptococcal meningitis

344.5

Monoplegia, unspecified

361.32

Horseshoe tear of retina without detachment

370.55

Corneal abscess

382.9

Otitis media, unspecified

Chapter 7—Diseases of the Circulatory System (Code Range 390–459) The circulatory system includes the heart, arteries, veins, and lymphatic system; therefore, cardiac disorders and arterial, venous, and some lymphatic diseases are contained in this chapter. EXAMPLE: Using volume 1 of your ICD-9-CM book, locate the start of chapter 7. Here you will find the code listing for diseases of the heart, arteries, arterioles, capillaries, vein, and lymphatic system. Reference the following codes to familiarize yourself with this chapter. Diagnostic Code

Diagnostic Description

391.0

Acute rheumatic pericarditis

401.0

Malignant hypertension

429.82

Hyperkinetic heart disease

457.2

Lymphangitis

459.0

Hemorrhage, unspecified

Chapter 8—Diseases of the Respiratory System (Code Range 460–519) Diseases of the pharynx, larynx, trachea, bronchus, vocal cords, sinuses, nose, tonsils and adenoids, and parts of the lung are coded from this chapter. EXAMPLE: Using volume 1 of your ICD-9-CM book, locate the start of chapter 8. Here you will find the code listing for diseases of the respiratory system. Reference the following codes to familiarize yourself with this chapter. Diagnostic Code

Diagnostic Description

461.0

Acute maxillary sinusitis

462

Acute pharyngitis

473.2

Ethmoidal sinusitis, chronic

491.0

Simple chronic bronchitis

519.4

Disorders of diaphragm

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Section I

Introduction to Coding

Chapter 9—Diseases of the Digestive System (Code Range 520–579) Diseases of the oral cavity, salivary glands, jaws, esophagus, stomach, duodenum, appendix, abdominal cavity, small and large intestine, peritoneum, anus, liver, gallbladder, biliary tract, and pancreas are contained within this chapter. EXAMPLE: Using volume 1 of your ICD-9-CM book, locate the start of chapter 9. Here you will find the code listing for diseases of the digestive system. Reference the following codes to familiarize yourself with this chapter. Diagnostic Code

Diagnostic Description

520.3

Mottled teeth

526.1

Fissural cysts of jaw

530.12

Acute esophagitis

537.1

Gastric diverticulum

553.21

Incisional ventral hernia

Chapter 10—Diseases of the Genitourinary System (Code Range 580–629) Coded from this chapter are diseases of the kidney, ureter, urinary bladder, urethra, male genital organs, male and female breast, and female genital organs (not involving pregnancy, childbirth, and the postpartum period). EXAMPLE: Using volume 1 of your ICD-9-CM book, locate the start of chapter 10. Here you will find the code listing for diseases of the genitourinary system. Reference the following codes to familiarize yourself with this chapter. Diagnostic Code

Diagnostic Description

584.6

Acute renal failure with lesion of renal cortical necrosis

592.1

Calculus of ureter

602.2

Atrophy of prostate

614.0

Acute salpingitis and oophoritis

629.1

Hydrocele, canal of nuck

Chapter 11—Complications of Pregnancy, Childbirth, and the Puerperium (Code Range 630–677) This chapter includes ectopic and molar pregnancies, spontaneous abortions, legally and illegally induced abortions, and complications of pregnancy, abortions, labor and delivery, and the postpartum period. EXAMPLE: Using volume 1 of your ICD-9-CM book, locate the start of chapter 11. Here you will find the code listing for complications of pregnancy, childbirth, and the puerperium. Reference the following codes to familiarize yourself with this chapter.

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Diagnostic Code

Diagnostic Description

630

Hydatidiform mole

632

Missed abortion

650

Normal delivery

675.04

Postpartum infection of nipple

676.44

Failure of lactation, postpartum, 2 weeks after delivery

19

Chapter 12—Diseases of the Skin and Subcutaneous Tissue (Code Range 680–709) This chapter includes inflammatory and infectious conditions of the skin and subcutaneous tissue, as well as diseases of the nail, hair and hair follicles, sweat, and sebaceous glands. EXAMPLE: Using volume 1 of your ICD-9-CM book, locate the start of chapter 12. Here you will find the code listing for diseases of the subcutaneous tissue and skin. Reference the following codes to familiarize yourself with this chapter. Diagnostic Code

Diagnostic Description

681.10

Cellulitis and abscess of the toe, unspecified

685.0

Pilonidal cyst with abscess

703.0

Ingrowing nail

708.3

Dermatographic urticaria

709.2

Cicatrix

Chapter 13—Diseases of the Musculoskeletal System and Connective Tissue (Code Range 710–739) This chapter includes diseases of the bones, joints, bursa, muscles, ligaments, tendons, and soft tissues. EXAMPLE: Using volume 1 of your ICD-9-CM book, locate the start of chapter 13. Here you will find the code listing for diseases of the musculoskeletal system and connective tissue. Reference the following codes to familiarize yourself with this chapter. Diagnostic Code

Diagnostic Description

710.1

Systemic sclerosis

714.0

Rheumatoid arthritis

724.5

Backache, unspecified

734

Flat foot

738.4

Acquired spondylolisthesis

Chapter 14—Congenital Anomalies (Code Range 740–759) This chapter contains any congenital anomaly regardless of the body system involved. A congenital anomaly is an anomaly present at or existing from the time of birth. EXAMPLE: Using volume 1 of your ICD-9-CM book, locate the start of chapter 14. Here you will find the code listing for congenital anomalies. Reference the following codes to familiarize yourself with this chapter.

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Section I

Introduction to Coding

Diagnostic Code

Diagnostic Description

740.0

Anencephalus

742.3

Congenital hydrocephalus

747.82

Spinal vessel anomaly

751.62

Congenital cystic disease of the liver

758.0

Down’s syndrome

Chapter 15—Certain Conditions Originating in the Perinatal Period (Code Range 760–779) This chapter includes conditions that have their origin in the perinatal period, a period of time before birth through the first 28 days after birth. EXAMPLE: Using volume 1 of your ICD-9-CM book, locate the start of chapter 15. Here you will find the code listing for conditions originating in the perinatal period. Reference the following codes to familiarize yourself with this chapter. Diagnostic Code

Diagnostic Description

760.4 766.22 770.3 776.6 779.31

Maternal nutritional disorders Prolonged gestation of infant Pulmonary hemorrhage of fetus and newborn Anemia of prematurity Feeding problems in newborn

Chapter 16—Symptoms, Signs, and Ill-Defined Conditions (Code Range 780–799) This chapter includes symptoms, signs, abnormal results of laboratory tests and investigative procedures, and ill-defined conditions. EXAMPLE: Using volume 1 of your ICD-9-CM book, locate the start of chapter 16. Here you will find the code listing for symptoms, signs, and ill-defined conditions. Reference the following codes to familiarize yourself with this chapter. Diagnostic Code

Diagnostic Description

780.01

Coma

780.53

Hypersomnia with sleep apnea, unspecified

781.2

Abnormality of gait

786.2

Cough

796.1

Abnormal reflex

Chapter 17—Injury and Poisoning (Code Range 800–999) This chapter includes fractures, dislocations, sprains and strains of joints and muscles, intracranial injuries, and internal injuries to chest, abdomen, and pelvis. Open wounds, superficial injuries, contusions, burns, and poisonings by drugs and medicinal and biological substances are also coded from this chapter. Late effects of previous conditions are contained in this chapter as well.

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EXAMPLE: Using volume 1 of your ICD-9-CM book, locate the start of chapter 17. Here you will find the code listing for injuries and poisonings. Reference the following codes to familiarize yourself with this chapter. Diagnostic Code

Diagnostic Description

808.1

Fracture of the acetabulum, open

830.0

Closed dislocation of jaw

845.00

Sprained ankle, unspecified

922.1

Contusion, chest wall

991.2

Frostbite of foot

Exercise 2–2

Identifying Diseases and Chapter Titles

Using the Tabular List of Diseases and Injuries, complete the following table. List the name or description of the disease found in the Tabular and the chapter title. The first one is completed. Code Number

Description

Chapter Title

078.2

Sweating fever

Infectious and Parasitic Disease

155.0 003.1 210.7 371.40 729.5 464.00 787.02 537.1

Volume 1—Supplementary Classifications The second subdivision of volume 1 consists of Supplementary Classifications, also known as V codes and E codes. These two supplementary classifications are used in combination with codes from the preceding chapters or, in the case of V codes, are used alone to code conditions and/or situations for which there is no code in one of the other chapters. E codes are never used without a code from the 17 chapters.

V Codes—Supplementary Classification of Factors Influencing Health Status and Contact with Health Services (Code Range V01–V86) The Supplementary Classification of Factors Influencing Health Status and Contact with Health Services section is used to code those conditions or circumstances that are recorded as the reason for the patient encounter when the patient is not currently ill, or when a factor is present that affects the

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Section I

Introduction to Coding

patient’s health status and/or medical management of the patient’s case. Specific instructions for assigning V codes are found in the chapter entitled “V Codes.” EXAMPLE: Using volume 1 of your ICD-9-CM book, locate the start of “V Codes,” which is after chapter 17, “Injury and Poisoning.” Here you will find the Supplementary Classification of Factors Influencing Health Status and Contact with Health Services, or V codes. Reference the following codes to familiarize yourself with this chapter. V Code

V Code Description

V01.3

Contact with or exposure to smallpox

V12.1

Personal history of nutritional deficiency

V52.2

Fitting and adjustment of artificial eye

V72.0

Examination of eyes and vision

V82.6

Multiphasic screening

E Codes—Supplementary Classification of External Causes of Injury and Poisoning (Code Range E800–E999) The Supplementary Classification of External Causes of Injury and Poisoning section is used to provide a classification for external causes of injuries and poisonings. E codes identify the environmental event, circumstance, or condition that is the cause for the injury or poisoning. These codes are used in addition to a code from one of the main chapters. Specific instructions for assigning these codes are found in the chapter entitled “E Codes.” EXAMPLE: Using volume 1 of your ICD-9-CM book, locate the start of the “E Codes.” This follows the chapter on V codes. Here you will find the Supplementary Classification of External Causes of Injury and Poisoning, or E codes. Reference the following codes to familiarize yourself with this chapter. E Code

E Code Description

E847

Accidents involving cable cars not running on rails

E869.0

Accidental poisoning by nitrogen oxides

E884.2

Fall from chair

E963

Assault by hanging and strangulation

E978

Legal Execution

Exercise 2–3

V Codes and E Codes

True/False: Referencing the chapters for V codes and E codes, answer true (T) or false (F).

3.

Code E907 is the code for accidents due to lightning. A family history of a malignant neoplasm of the gastrointestional tract is coded to V10.00. The E code range E800–E807 codes railway accidents.

4.

The V code range V16–V19 codes family histories of conditions.

5.

Code E979.4 is the code for terrorism involving firearms.

1. 2.

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Volume 1—Appendices The third subdivision of volume 1 of ICD-9-CM is the Appendices, which contain reference information. There are five appendices in this volume.

Appendix A—Morphology of Neoplasms (Code Range M8000/0–M9970/1) Appendix A, “Morphology of Neoplasms,” contains a nomenclature of the morphology of neoplasms adapted from the International Classification of Diseases (ICD) of Oncology and is used with codes from chapter 2, depending on the setting of the encounter.

Appendix B—Glossary of Mental Disorders This appendix was officially deleted October 1, 2004.

Appendix C—Classification of Drugs by American Hospital Formulary Service List Number and Their ICD-9-CM Equivalents Appendix C, “Classification of Drugs by American Hospital Formulary Service List Number and Their ICD-9-CM Equivalents,” lists the ICD-9-CM diagnosis code for the coding of poisonings by drugs and medicinal and biological substances in relation to the listing of drugs by the American Hospital Formulary Service.

Appendix D—Classification of Industrial Accidents According to Agency This appendix was officially removed effective with the October 2009 update.

Appendix E—List of Three-Digit Categories Appendix E, “List of Three-Digit Categories,” is a listing of all the three-digit categories that are found in ICD-9-CM.

Volume 2—Alphabetic Index Volume 2 of ICD-9-CM has three major subdivisions. The first subdivision is the Index to Diseases and Injuries. This section functions as the key to the coding system. It contains an alphabetical listing of the diseases and injuries classified in ICD-9-CM. This section will be discussed in more detail in a later chapter. The second subdivision is the Alphabetic Index to Poisoning and External Causes of Adverse Effects of Drugs and Other Chemical Substances, commonly referred to as the Table of Drugs and Chemicals. This table is used to classify poisonings by a drug or chemical, as well as to classify external causes of an adverse effect of a drug or chemical. The third subdivision is the Alphabetic Index to External Causes of Injury and Poisoning. This is the index for E codes, which classify environmental events, circumstances, and other conditions as the cause of an injury and adverse effects. The Alphabetic Indices follow alphabetization rules that are unique to ICD-9-CM. These rules will be discussed in Chapter 3.

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Section I

Introduction to Coding

Volume 3—Tabular List and Alphabetic Index of Procedures The third volume of ICD-9-CM, known as the Tabular List and Alphabetic Index of Procedures, contains both the alphabetic and tabular list for procedures and surgeries. The Tabular List is organized according to the location of the procedure or is grouped into the chapter for miscellaneous diagnostic and therapeutic procedures. The content of the various chapters will be discussed in detail in later chapters. EXAMPLE: Refer to the following list. You will see that the chapters are organized by the location of the procedure; for example, chapter 1 is “Operations on the Nervous System” and chapter 4 is “Operations on the Ear.” Chapter Titles and Category Codes of Tabular List of Procedures 00. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16.

Procedures and Interventions, Not Elsewhere Classified (00) Operations on the Nervous System (01–05) Operations on the Endocrine System (06–07) Operations on the Eye (08–16) Operations on the Ear (18–20) Operations on the Nose, Mouth, and Pharynx (21–29) Operations on the Respiratory System (30–34) Operations on the Cardiovascular System (35–39) Operations on the Hemic and Lymphatic Systems (40–41) Operations on the Digestive System (42–54) Operations on the Urinary System (55–59) Operations on the Male Genital Organs (60–64) Operations on the Female Genital Organs (65–71) Obstetrical Procedures (72–75) Operations on the Musculoskeletal System (76–84) Operations on the Integumentary System (85–86) Miscellaneous Diagnostic and Therapeutic Procedures (87–99)

Exercise 2–4

Tabular List of Procedures

To become familiar with volume 3, complete the following table using the Tabular List of Procedures. The first one is completed. Procedural Code

Procedural Description

Procedure Chapter Title

22.71

Closure of nasal sinus fistula

Operations on the Nose, Mouth, and Pharynx

07.72 18.31 43.99 35.42 31.45 66.4 55.04 96.41

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Procedural Code

Procedural Description

An Overview of ICD-9-CM

25

Procedure Chapter Title

08.41 84.21 75.7 00.03 01.32 41.06 85.25 60.61 83.31

Internet Links The National Center for Health Statistics (NCHS) maintains information about ICD-9-CM. For a wealth of information, explore http://www.cdc.gov/nchs/icd9.htm.

Summary • ICD-9-CM consists of three volumes. • Volume 1 is the Tabular List of Diseases and Injuries. • Volume 2 is the Alphabetic Index. • Volume 3 is the Tabular List and Alphabetic Index of Procedures. • The Tabular List of Diseases and Injuries has three major subdivisions: the Classification of Diseases and Injuries, Supplementary Classifications, and Appendices. • The Classification of Diseases and Injuries is a numerical list of diseases and injuries found in ICD-9-CM. • The Supplementary Classifications of ICD-9-CM are known as V codes and E codes. • V codes are used to code the conditions or circumstances that are recorded as the reason for the patient encounter, as well as factors that affect the patient’s health and/or medical management. • E codes provide a classification for external causes of injuries and poisonings. • The appendices in volume 1 serve as reference material for the coder. • The Alphabetic Index in volume 2 has three major subdivisions: the Index to Diseases and Injuries, the Alphabetic Index to Poisoning and External Causes of Adverse Effects of Drugs and Other Chemical Substances, and the Table of Drugs and Chemicals. • Volume 3, the Tabular List and Alphabetic Index of Procedures, contains both the tabular and alphabetic list of procedures and surgeries.

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Section I

Introduction to Coding

Chapter Review True/False: Indicate whether each statement is true (T) or false (F). 1.

Volume 2 is the Tabular List of Diseases and Injuries.

2.

V codes and E codes must be used with an additional code from the main chapters of ICD-9-CM.

3.

Volume 3 is the Tabular List and Alphabetic Index of Procedures and is used in the facility setting.

4.

E codes are used to code conditions or circumstances that are recorded as the reason for the patient encounter when the patient is not currently ill.

5.

Family and personal histories of diseases are coded to different V codes.

Fill-in-the-Blank: Enter the appropriate term(s) to complete each statement below. 6. The diagnostic chapters of ICD-9-CM are organized according to the cause of disease, or involved.

, , the body system

contains an alphabetical listing of the 7. The diseases and injuries found in ICD-9-CM and serves as a key to the coding system. 8. The codes that provide a classification for external causes of injuries and poisonings are known as . , entitled , includes fractures, dislocations, sprains and strains 9. Chapter of joints and muscles, intracranial injuries, and internal injuries to chest, abdomen, and pelvis. 10. Disorders and diseases of the thyroid and other endocrine glands, nutritional deficiencies, metabolic disorders, and disorders of the immune mechanism and immunity deficiencies are contained in chapter , entitled . Short Answer: Briefly respond to each question. 11. Discuss the content of the three volumes of ICD-9-CM.

12. Explain the difference between a diagnostic code and a procedural code. Give an example of each.

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13. Summarize the content of chapter 16, “Signs, Symptoms, and Ill-Defined Conditions.”

14. Identify the appendices that are found in volume 1 of ICD-9-CM.

15. Explain the purpose of E codes.

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CHA PTER

3

ICD-9-CM Volume Organization

Chapter Outline Introduction Volume 1—Tabular List of Diseases and Injuries Volume 2—Alphabetic Index to Diseases and Injuries

Volume 3—Tabular List and Alphabetic Index of Procedures Summary Chapter Review

Objectives At 1. 2. 3. 4. 5.

the conclusion of this chapter, the student will be able to: Discuss the organization of the three volumes of ICD-9-CM. Explain the procedure for referencing main terms in the index of ICD-9-CM. Outline the alphabetizing rules used in the index. Locate main terms in the disease and procedure indices. Identify valid and truncated codes.

Key Terms Accident Adverse Effect Assault Category

Main Terms Poisoning Sections

Subcategory Subclassification Suicide Attempt

Therapeutic Use Truncated Codes Undetermined

Reminder As you work through this chapter, you will need to have a copy of the ICD-9-CM coding book to reference.

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ICD-9-CM Volume Organization

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Introduction As discussed previously, ICD-9-CM is organized into chapters, appendices, and indices. This chapter will discuss the organization and arrangement of the divisions of the volumes of ICD-9-CM.

Volume 1—Tabular List of Diseases and Injuries The 17 chapters of the ICD-9-CM, including V codes and E codes, are arranged at the chapter level according to body systems, etiology, or situations affecting the onset of the conditions. A range of codes is assigned to each chapter. For example, chapter 1, “Infectious and Parasitic Diseases,” contains codes in the range 001–139. Figure 3-1 illustrates the beginning of chapter 1 and is an example of the code ranges.

1. INFECTIOUS AND PARASITIC DISEASES (001–139) Note: Categories for “late effects” of infectious and parasitic diseases are to be found at 137–139. Includes:

Diseases generally recognized as communicable or transmissible as well as a few diseases of unknown but possibly infectious origin

Excludes:

Acute respiratory infections (460–466) Carrier or suspected carrier of infectious organism (V02.0–V02.9) Certain localized infections Influenza (487.0–487.8, 488.0–488.1) INTESTINAL INFECTIOUS DISEASES (001–009)

Excludes: 001

Helminthiases (120.0–129) Cholera 001.0 001.1 001.9

002

Typhoid and paratyphoid fevers 002.0 002.1 002.2 002.3 002.9

003

Due to Vibrio cholerae Due to Vibrio cholerae el tor Cholera, unspecified

Typhoid fever Typhoid (fever) (infection) [any site] Paratyphoid fever A Paratyphoid fever B Paratyphoid fever C Paratyphoid fever, unspecified

Other salmonella infections

Includes:

Infection or food poisoning by Salmonella [any serotype] 003.0 003.1 003.2

003.8 003.9

Salmonella gastroenteritis Salmonellosis Salmonella septicemia Localized salmonella infections 003.20 Localized salmonella infection, unspecified 003.21 Salmonella meningitis 003.22 Salmonella pneumonia 003.23 Salmonella arthritis 003.24 Salmonella osteomyelitis 003.29 Other Other specified salmonella infections Salmonella infection, unspecified

Figure 3-1 ICD-9-CM chapter 1, “Infectious and Parasitic Diseases”

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Section I

Introduction to Coding

Chapters within ICD-9-CM are divided into sections, which contain a series of three-digit category codes that group conditions or related conditions. Figure 3-1 also illustrates the first section, “Intestinal Infectious Diseases” (001–009), of chapter 1. Reference an ICD-9-CM code book, and note that chapter 1 is divided into the following sections: Section

Code Range

Intestinal Infectious Diseases

001–009

Tuberculosis

010–018

Zoonotic Bacterial Diseases

020–027

Other Bacterial Diseases

030–041

Human Immunodeficiency Virus [HIV] Disease

042

Poliomyelitis and Other Non-Arthropod-Borne Viral Diseases and Prion Diseases of Central Nervous System

045–049

Viral Diseases Generally Accompanied by Exanthem

050–059

Arthropod-Borne Viral Diseases

060–066

Other Diseases Due to Viruses and Chlamydiae

070–079

Rickettsioses and Other Arthropod-Borne Diseases

080–088

Syphilis and Other Venereal Diseases

090–099

Other Spirochetal Diseases

100–104

Mycoses

110–118

Helminthiases

120–129

Other Infectious and Parasitic Diseases

130–136

Codes are not assigned from chapter or section levels. Code assignment starts at the category level with three-digit codes. Codes are assigned at this level only if the category level is not further divided into a subcategory, with codes containing four digits, or into a subclassification, with codes containing five digits. An example of a valid category code is code number 490, “Bronchitis, not specified as acute or chronic” (Figure 3-2). Because the category is not divided into subcategory fourdigit codes or subclassification five-digit codes, the coder can select 490. If a category is divided into subcategories, the coder must code at the four-digit level. Category code 491, “Chronic bronchitis,” is divided into subcategories, so code 491 would not be valid. The coder must use four digits to code the chronic bronchitis. The acceptable four-digit codes are 491.0, 491.1, 491.8, and 491.9. Note that subcategory code 491.2 is divided into a subclassification five-digit code; as a result, 491.2 is not valid. Code 491.20 or 491.21 or 491.22 needs to be used. Codes that do not contain all the necessary digits are truncated codes. Truncated codes are codes that are not carried out to the most specific classification available for a category. If invalid truncated codes are used, claims will be rejected by Medicare and other third-party payers. EXAMPLE: Dr. Matthews’ office submits code number 491 as the primary diagnosis code for chronic bronchitis on a claim submitted for third-party reimbursement. The claim is rejected by the third-party payer because the diagnosis was not coded to the fourth or fifth digit. Since Dr. Matthews did not specify the type of chronic bronchitis, the coder should have submitted code 491.9, “unspecified chronic bronchitis.” At the time of the initial office visit, a specific diagnosis may not be known. In this situation, either the unspecified diagnosis code or the code(s) for any associated symptoms that required medical attention should be submitted. Subcategory codes, those containing four digits, can be used only if no subclassification codes are available. Subclassification codes, those codes containing five digits, are the most specific codes available in the coding system. Whenever five-digit codes are present in ICD-9-CM, they must be used.

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31

CHRONIC OBSTRUCTIVE PULMONARY DISEASE AND ALLIED CONDITIONS (490–496) 490

Bronchitis, not specified as acute or chronic Bronchitis NOS: Catarrhal with tracheitis NOS Tracheobronchitis NOS Excludes: Bronchitis: allergic NOS (493.9) asthmatic NOS (493.9) due to fumes and vapors (506.0)

491

Chronic bronchitis

Excludes:

Chronic obstructive asthma (493.2) 491.0 491.1

491.2

Simple chronic bronchitis Catarrhal bronchitis, chronic Smokers' cough Mucopurulent chronic bronchitis Bronchitis (chronic) (recurrent): fetid mucopurulent purulent Obstructive chronic bronchitis Bronchitis: emphysematous obstructive (chronic) (diffuse) Bronchitis with: chronic airway obstruction emphysema Excludes: Asthmatic bronchitis (acute) (NOS) (493.9) Chronic obstructive asthma (493.2)

491.20 491.21

Without exacerbation Emphysema with chronic bronchitis With (acute) exacerbation Acute exacerbation of chronic obstructive pulmonary disease [COPD] Decompensated chronic obstructive pulmonary disease [COPD] Decompensated chronic obstructive pulmonary disease [COPD] with exacerbation Excludes: Chronic obstructive asthma with acute exacerbation (493.22)

491.22

With acute bronchitis

491.8

Other chronic bronchitis Chronic: Tracheitis Tracheobronchitis Unspecified chronic bronchitis

491.9

Figure 3-2 ICD-9-CM code categories 490–491

The fifth digits are displayed in the text of the code description, as in codes 491.20 and 491.21, or displayed after a category heading, as in code 493 (Figure 3-3). For subcategory codes 493.0, 493.1, 493.2, and 493.9, the coder must select the proper fifth digit of 0, 1, or 2. These subcategory codes are not valid codes without the fifth digit. Note that for code 493.8 the fifth digit is displayed in the text of the code description.

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Section I

Introduction to Coding

493

Asthma Excludes:

Wheezing NOS (786.07)

The following fifth-digit subclassification is for use with category 493.0–493.2, 493.9: 0 Unspecified 1 With status asthmaticus 2 With (acute) exacerbation 493.0

Extrinsic asthma Asthma: Allergic with stated cause Atopic Childhood Hay Platinum Hay fever with asthma Excludes:

asthma: allergic NOS (493.9) detergent (507.8) miners’ (500) wood (495.8)

493.1

Intrinsic asthma Late-onset asthma

493.2

Chronic obstructive asthma Asthma with chronic obstructive pulmonary disease [COPD] Chronic asthmatic bronchitis Excludes:

493.8

Other forms of asthma 493.81 Exercise induced bronchospasm 493.82

493.9

Acute bronchitis (466.0) Chronic obstructive bronchitis (491.20–491.22)

Cough variant asthma

Asthma, unspecified Asthma (bronchial) (allergic NOS) Bronchitis: allergic asthmatic

Figure 3-3 ICD-9-CM code category 493

ICD-9-CM Official Coding Guidelines for Coding and Reporting As you can see, ICD-9-CM diagnosis codes are composed of codes with three, four, or five digits. Diagnosis and procedure codes should be used with the highest number of digits available, with the coder following any subdivisions to obtain the greatest detail. A code is invalid if it has not been coded to the full number of digits required. EXAMPLE: Acute myocardial infarction, code 410, has fourth digits available to describe the location of the infarction (i.e., 410.2, of inferolateral wall) and fifth digits to identify the episode of care (i.e., 410.21, of inferolateral wall, initial episode of care). It would be incorrect to report a code in category 410 without a fourth and fifth digit.

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It should be noted that procedure codes in ICD-9-CM volume 3 should have three or four digits. Two-digit codes are included in ICD-9-CM as headings that may be subdivided into codes with three or four digits, which provide greater detail. This will be discussed later in the chapter.

Volume 2—Alphabetic Index to Diseases and Injuries The key to locating diagnoses codes is found in volume 2, “Alphabetic Index to Diseases and Injuries.” The first section of volume 2, “Index to Diseases and Injuries,” is used to locate codes for diseases, injuries, and V codes. V codes are used to code factors that influence health status and contacts with health services. The second section, “Table of Drugs and Chemicals,” is used to locate the code for poisonings from drugs and chemicals and external cause of adverse effects. The third section of this volume, “The Index to External Causes of Injury,” is used to locate E codes. E codes are used to classify environmental events, circumstances, and other conditions as the cause of injury and other adverse effects. V codes and E codes will be explained in more detail later in this book. The alphabetic indices are organized by main terms. These main terms are printed in bold type and follow letter-by-letter alphabetizing. Rules of letter-by-letter alphabetizing are as follows: 1. Ignore single spaces when alphabetizing. 2. Ignore single hyphens when alphabetizing. 3. Numbers or the adjective version of the number (first, second, third, fourth) are placed in numerical order before alphabetical characters. 4. When a diagnostic statement contains the term with, the with immediately follows the main term, and the second part of the diagnosis follows in alphabetical order. 5. Subterms and modifying terms are indented under the main term. They appear in alphabetical order.

Location of Main Term Location of the main term in the alphabetic index is the key to correct code selection. Main terms identify the disease, sign, symptom, condition, or injury to be coded. Main terms for volume 2 are located in the alphabetic index by referencing the condition or injury that is present, and they start with a capital letter that is printed on the left-hand margin. Figure 3-4 represents a page from volume 2 that shows the main terms appendage, appendicitis, appendiclausis, appendicolithiasis, and appendicopathia oxyurica. EXAMPLE: The diagnostic phrase chronic appendicitis is located in the index by referencing the term appendicitis. Figure 3-4 represents a page from volume 2 for locating the diagnostic phrase chronic appendicitis. The coder first references the main term, appendicitis, and then locates the subterm chronic. The code 542 appears next to the term chronic (recurrent). Note that when in parentheses, the term does or does not need to be included in the diagnostic statement. This coding rule will be discussed in a later chapter. Locate the following diseases or injuries in volume 2, “Alphabetic Index to Diseases and Injuries,” by referencing the main term. Note the codes found in the index. Disease or Condition

Main Term in Index

Code Found in Index

Chronic appendicitis

Appendicitis

542

Dancing disease

Disease

297.8

Hemorrhagic encephalitis

Encephalitis

323.9

Fracture of arm

Fracture

818.0

Open wound of shin with tendon involvement

Wound

891.2

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Section I

Introduction to Coding

Appendage fallopian tube (cyst of Morgagni) 752.11 intestine (epiploic) 751.5 preauricular 744.1 testicular (organ of Morgagni) 752.89 Appendicitis 541 with perforation, peritonitis (generalized), or rupture 540.0 with peritoneal abscess 540.1 peritoneal abscess 540.1 acute (catarrhal) (fulminating) (gangrenous) (inflammatory) (obstructive) (retrocecal) (suppurative) 540.9 with perforation, peritonitis, or rupture 540.0 with peritoneal abscess 540.1 peritoneal abscess 540.1 amebic 006.8 chronic (recurrent) 542 exacerbation - see Appendicitis, acute fulminating - see Appendicitis, acute gangrenous - see Appendicitis, acute healed (obliterative) 542 interval 542 neurogenic 542 obstructive 542 pneumococcal 541 recurrent 542 relapsing 542 retrocecal 541 subacute (adhesive) 542 subsiding 542 suppurative—see Appendicitis, acute tuberculous (see also Tuberculosis) 014.8 Appendiclausis 543.9 Appendicolithiasis 543.9 Appendicopathia oxyurica 127.4

Figure 3-4 Example of some main terms in the Alphabetic Index to Diseases and Injuries

Exercise 3–1

Identifying Main Terms

For each diagnostic phrase listed, identify the main term that would be located in the index. Disease or Condition

Main Term in Index

1. Amnion hematoma 2. Degenerative arthritis 3. Raynaud’s gangrene 4. Nonfamilial hemophilia 5. Hepatic infarct 6. Spinal cord injury 7. Ankle sprain

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Disease or Condition

ICD-9-CM Volume Organization

35

Main Term in Index

8. Patellar tendonitis 9. Acquired deformity of ankle 10. Amebic lung abscess 11. Chronic bronchitis 12. Senile dementia 13. Fracture of left 4th rib 14. Renal hypertension 15. Allergic enteritis

Tables of Drugs and Chemicals The second section of volume 2, “Table of Drugs and Chemicals,” is used to locate codes for poisonings and the external cause. Drugs and chemical substances are listed alphabetically. The second column, poisoning, represents the code for the classification of the poisoning, according to the type of drug or chemical that the patient was exposed to. The remaining five columns, listed under external causes, represent the causes of the poisoning or adverse reactions. Figure 3-5 represents an excerpt from a page of the Table of Drugs and Chemicals. Conditions are classified as a poisoning when a drug, chemical, or biological substance has been taken by a patient when it was not given under the direction of a physician. Examples include overdose; intoxication; wrong substance given or taken in error; medications taken with alcohol, prescription, and over-the-counter drugs combined; and wrong dosage taken. These conditions are coded as follows: 1. Reference Table of Drugs and Chemicals, poisoning column, under the main term of the drug or chemical the patient was exposed to. Select poisoning code. 2. Code any manifestation that is present from the Alphabetical Index to Diseases and Injuries (e.g., gastritis, coma, shock). EXTERNAL CAUSES (E Code) Substance

Poisoning

Accident

Therapeutic Use

Suicide Attempt

Assault

Undetermined

Acetone (oils) (vapor)

982.8

E862.4

-----

E950.9

E962.1

E980.9

Acetophenazine (maleate)

969.1

E853.0

E939.1

E950.3

E962.0

E980.3

Acetophenetidin

965.4

E850.4

E935.4

E950.0

E962.0

E980.0

Acetophenone

982.0

E862.4

-----

E950.9

E962.1

E980.9

Acetorphine

965.09

E850.2

E935.2

E950.0

E962.0

E980.0

Acetosulfone (sodium)

961.8

E857

E931.8

E950.4

E962.0

E980.4

Figure 3-5 Excerpt from Table of Drugs and Chemicals

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Section I

Introduction to Coding

3. Select the external cause of the poisoning from one of the following columns: Accident (E850–E869)—This includes accidental overdose of a drug, wrong substance given or taken, drug taken inadvertently, accidents in the usage of drugs and biologicals in medical and surgical procedures, and to show external causes of poisonings classifiable to 980–989. Suicide attempt (E950–E952)—These are self-inflicted attempts by means of drugs and chemicals. Assault (E961–E962)—An injury or poisoning inflicted by another person with the intent to injure or kill. Undetermined (E980–E982)—These codes are used when the intent of the poisoning cannot be determined as to whether it was intentional or accidential. The column Therapeutic Use is not to be used with a poisoning code and is used when there is an adverse effect. An adverse effect is defined as a reaction to the correct administration of a drug or a reaction between two or more drugs that were prescribed by a physician. The following steps should be used when coding an adverse effect: 1. Locate the reaction or condition present in the Alphabetic Index to Diseases and Injuries (e.g., rash, vomiting, swelling). 2. Locate the E code for the adverse effect on the Table of Drugs and Chemicals, in the Therapeutic Use column. EXAMPLE: A physician prescribes erythromycin, and the patient develops an allergic rash. Because this is an adverse effect to a drug properly taken, the coder codes the allergic rash as 693.0 and then references the Table of Drugs and Chemicals to code the erythromycin as the cause of the rash; this is code E930.3. Additional E codes are located by using the third section of volume 2, “The Alphabetic Index to External Causes of Injury and Poisoning (E Codes).” E codes have become of interest to third-party payers as well as to governmental agencies and health departments. The presence of the E code shows the cause of an injury or accident and therefore can be helpful in determining the most appropriate financial coverage for the injury, such as workmen’s compensation, homeowner’s insurance, and so on. The main terms for this section are organized by the term that describes the accident, the circumstances, or the specific agent that was the cause of the injury or adverse effect. It is important for the coder to use the following rules when selecting E codes: 1. E codes are supplemental codes and are never reported without a code from the main classification (code range 001–999). 2. The letter E must always be reported in addition to the numerical characters. 3. The diagnosis being coded is reported first and is followed by the E code. E codes are located by one of the following: 1. Referencing the Table of Drugs and Chemicals for codes for poisonings and adverse effects. 2. Referencing the Index to External Causes for codes for the cause of an injury or poisoning. Locate the following external causes for the examples listed in the Index to External Causes of Injury. Note the codes found in the index. Cause of Injury or Adverse Effect

Main Term in Index

Code Found in Index

Fracture due to fall from tree

Fall

E884.9

Internal injuries from stabbing

Stabbing

E966

Patient struck by lightning

Lightning

E907

Accidental poisoning by carbon monoxide fumes from car in motion, not on public highway

Poisoning

E825.9

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Exercise 3–2 of Injuries

ICD-9-CM Volume Organization

37

Identifying Main Terms for External Causes

For each injury listed, identify the main term that would be located in the Alphabetical Index to External Cause of Injury. Injury

Main Term in the Index to External Cause of Injury

1. Burn from contact with dry ice 2. Choking on an apple 3. Fall from a stepladder 4. Third-degree burns from house fire 5. Puncture wound from BB gun 6. Multiple lacerations from rape 7. Fracture of wrist from being trapped by door of elevator 8. Fainting due to sunstroke 9. Multiple fractures due to motor vehicle accident 10. Six-year-old child with multiple bruises from abuse by stepfather

Volume 3—Tabular List and Alphabetic Index of Procedures Both the Tabular List of Procedures and Alphabetic Index of Procedures are found in volume 3 of ICD-9-CM. The format of volume 3 is similar to that of volumes 1 and 2 except that procedure codes contain a maximum of four digits; diagnostic codes can contain a maximum of five digits. Figure 3-6 represents the start of the first chapter of the Tabular List of Procedures, entitled “Procedures and Interventions, Not Elsewhere Classified (00).” Note that the codes contain no more than four digits. Reference an ICD-9-CM code book and locate the second chapter of the Tabular List of Procedures, entitled “Operations on the Nervous System.” Note the following category codes found in this chapter. Category Description

Category Code

Incision and excision of skull, brain, and cerebral meninges

01

Other operations on skull, brain, and cerebral meninges

02

Operations on spinal cord and spinal canal structures

03

Operations on cranial and peripheral nerves

04

Operations on sympathetic nerves or ganglia

05

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Section I

Introduction to Coding

PROCEDURES AND INTERVENTIONS, NOT ELSEWHERE CLASSIFIED (00) 00

Procedures and interventions, Not Elsewhere Classified

00.0

Therapeutic ultrasound Excludes: Diagnostic ultrasound (non-invasive) (88.71–88.79) Intracardiac echocardiography [ICE] (heart chamber(s)) (37.28) Intravascular imaging (adjunctive) (00.21–00.29) 00.01

Therapeutic ultrasound of vessels of head and neck Anti-restenotic ultrasound Intravascular non-ablative ultrasound Excludes: Diagnostic ultrasound of: eye (95.13) head and neck (88.71) That of inner ear (20.79) Ultrasonic: Angioplasty of non-coronary vessel (39.50) Embolectomy (38.01, 38.02) Endarterectomy (38.11, 38.12) Thrombectomy (38.01, 38.02)

00.02

Therapeutic ultrasound of heart Anti-restenotic ultrasound Intravascular non-ablative ultrasound Excludes: Diagnostic ultrasound of heart (88.72) Ultrasonic ablation of heart lesion (37.34) Ultrasonic angioplasty of coronary vessels (00.66, 36.09)

00.03

Therapeutic ultrasound of peripheral vascular vessels Anti-restenotic ultrasound Intravascular non-ablative ultrasound Excludes: Diagnostic ultrasound of peripheral vascular system (88.77) Ultrasonic angioplasty of: Non-coronary vessel (39.50)

00.09

Other therapeutic ultrasound Excludes:

00.1

Ultrasonic: Fragmentation of urinary stones (59.95) Percutaneous nephrostomy with fragmentation (55.04) Physical therapy (93.35) Transurethral guided laser induced prostatectomy (TULIP) (60.21)

Pharamaceuticals 00.10

Implantation of chemotherapeutic agent Brain wafer chemotherapy Interstitial/intracavitary Excludes: Injection or infusion of cancer chemotherapeutic substance (99.25) 00.11

Infusion of drotrecogin alfa (activated) Infusion of recombinant protein

00.12

Administration of inhaled nitric oxide Nitric oxide therapy

00.13

Injection or infusion of nesiritide Human B-type natriuretic peptide (hBNP)

00.14

Injection or infusion of oxazolidinone class of antibiotics Linezolid injection

00.15

High-dose infusion interleukin-2 [IL-2] Infusion (IV bolus, CIV) interleukin Injection of aldesleukin Excludes:

Low-dose infusion interleukin-2 (99.28)

Figure 3-6 Procedures and Interventions, Not Elsewhere Classified (00)

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Exercise 3–3 Category Codes for Operations on the Nose, Mouth, and Pharynx Identify the description for each category code for operations on the nose, mouth, and pharynx in the following list. The first one is done. Category Code

Description of Category Code

1. 21 2. 22 3. 23

Operations on nose

4. 24 5. 25 6. 26 7. 27 8. 28 9. 29

Alphabetical Index to Procedures The procedure index follows the same alphabetization rules as in volume 2. Main terms represent procedures and operations. However, there are two exceptions regarding subterms. Subterms that start with as, by, and for sometimes immediately follow the main term or subterm. The words with and without will then follow the subterms. Figure 3.7 represents a page from the Alphabetical Index to Procedures. Note that the entry for thoracotomy is followed by the subterm as operative approach, and the entry for thrombectomy is followed by the subterm with endarterectomy. EXAMPLE: The term exploratory thoracotomy is located in the procedure index by referencing the term thoracotomy and then locating the subterm exploratory. The code is 34.02, as shown in Figure 3-7.

Exercise 3–4

Using the Alphabetical Index to Procedures

For each procedure or operation listed, identify the main term used to find the procedure in the Alphabetical Index to Procedures. Procedure or Operation

Main Term in Alphabetical Index to Procedures

1. Incision and drainage of abscess 2. Total hip replacement 3. Coronary artery bypass graft 4. Open reduction of fracture of ankle 5. Fiberglass cast application 6. Exploratory thoractomy 7. Cryotherapy of warts

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Section I

Introduction to Coding

Procedure or Operation

Main Term in Alphabetical Index to Procedures

8. Third toe amputation 9. Bone sequestrectomy 10. Abdominal thrombectomy

Thoracectomy 34.09 for lung collapse 33.34 Thoracentesis 34.91 Thoracocentesis 34.91 Thoracolysis (for collapse of lung) 33.39 Thoracoplasty (anterior) (extrapleural) (paravertebral) (posterolateral) (complete) (partial) 33.34 Thoracoscopy, transpleural (for exploration) 34.21 Thoracostomy 34.09 for lung collapse 33.32 Thoracotomy (with drainage) 34.09 as operative approach—omit code exploratory 34.02 Thoratec implantable ventricular assist device (IVAD) 37.66 Thoratec ventricular assist device (VAD) system 37.66 Three-snip operation, punctum 09.51 Thrombectomy 38.00 with endarterectomy—see Endarterectomy abdominal artery 38.06 vein 38.07 aorta (arch) (ascending) (descending) 38.04 arteriovenous shunt or cannula 39.49 bovine graft 39.49 coronary artery 36.09 head and neck vessel NEC 38.02 intracranial vessel NEC 38.01 lower limb artery 38.08 vein 38.09 mechanical endovascular head and neck 39.74 pulmonary vessel 38.05 thoracic vessel NEC 38.05 upper limb (artery) (vein) 38.03 Thromboendarterectomy 38.10 abdominal 38.16 aorta (arch) (ascending) (descending) 38.14 coronary artery 36.09 open chest approach 36.03 head and neck NEC 38.12 intracranial NEC 38.11 lower limb 38.18 thoracic NEC 38.15 upper limb 38.13

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41

ICD-9-CM Volume Organization

Summary • The tabular volumes of ICD-9-CM are arranged by chapters. • Chapters are divided into sections that contain three-digit category codes. • The assignment of codes start at the category level if the category is not further divided into a subcategory or subclassification. • Truncated codes are not valid for reporting. • Diagnosis and procedure codes must be used at their highest number of digits available. • The Index is used to locate codes for diseases, injuries, V codes, and E codes. • Main terms identify the term to be referenced in the index. • The Table of Drugs and Chemicals is used to locate codes for poisonings and the external cause. • Volume 3 contains both the Tabular List of Procedures and Alphabetic Index of Procedures.

Chapter Review True/False: Indicate whether each statement is true (T) or false (F). 1.

Categories contain a series of three digits that group conditions or related conditions.

2.

A subclassification contains codes with five digits.

3.

If a category is divided, the coder must code at the subcategory or subclassification level.

4.

The tabular sections of ICD-9-CM are organized by main terms.

5.

The main term referenced for the diagnostic statement “recurrent infectious bronchitis” would be bronchitis.

Fill-in-the-Blank: Enter the appropriate term(s) to complete each statement. 6.

Patient Smith has taken a drug overdose. This is known as a(n)

7.

Any injury or poisoning inflicted by another person with the intent to injure or kill is a(n)

. .

8.

The cause of an injury or accident is coded by using a(n)

9. Procedure codes contain a maximum of

. digits.

10. Codes that do not contain all necessary digits are called codes.

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Section I

Introduction to Coding

Short Answer: Complete each exercise by referencing an ICD-9-CM code book. 11.

Use volume 1, “Tabular List of Diseases and Injuries,” to complete the following list. Chapter Title

First Section in Chapter

Code Range of Section

Diseases of Circulatory System Diseases of Genitourinary System Neoplasms Mental Disorders Infectious and Parasitic Diseases Symptoms, Signs, and Ill-Defined Conditions Diseases of Respiratory System Diseases of the Nervous System and Sense Organs Diseases of Musculoskeletal and Connective Tissue 12.

Use the Alphabetical Index to Procedures to identify the main terms for the following procedures or operations. Procedure or Operation

Main Term

Nasal packing due to severe epistaxis Biopsy of cervical lymph nodes Repair of umbilical hernia Colonoscopy with polypectomy Left cardiac catheterization Laparoscopic cholecystectomy Partial hysterectomy Colon resection Manipulation of fracture of femur Open reduction of left tibia with insertion of screws

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ICD-9-CM Coding Conventions and Steps in Coding

CHAPT ER

4

Chapter Outline Introduction Convention Types Instructional Notations Punctuation Marks Abbreviations

Symbols Steps in Coding Summary Chapter Review

Objectives At the conclusion of this chapter, the student will be able to: 1. Describe the conventions used in ICD-9-CM. 2. Differentiate among the abbreviations, symbols, and instructional notations used in ICD-9-CM. 3. Identify and select main terms that are referenced in the Alphabetic Indices. 4. Summarize the steps in coding.

Key Terms Braces Code First Underlying Disease, Cause, or Condition Colon Conventions Excludes:

Exclusion Note Includes: Inclusion Note Instructional Notations Italicized Brackets

Not Elsewhere Classifiable (NEC) Not Otherwise Specified (NOS) Parentheses See:

See Also: See Category: Slanted Brackets Square Brackets Use Additional Code

Reminder As you work through this chapter, you will need to have a copy of the ICD-9-CM coding book to reference.

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Section I

Introduction to Coding

Introduction This chapter contains coding rules that highlight concepts that must be followed for accurate coding to occur. Appendix A (Section 1, A) of your textbook also lists the ICD-9-CM Official Guidelines for Coding and Reporting that are relevant to this chapter.

STOP

Stop!!! When you see a stop sign, you must stop and then proceed with caution. ICD-9-CM uses the equivalent of traffic signs to guide coders throughout the coding book. These traffic signs must be followed to ensure accurate coding. The text of ICD-9-CM uses conventions, a group of instructional notations, punctuation marks, abbreviations, and symbols. To code accurately, a coder must have an understanding of the definitions for each of these conventions.

Convention Types There are four types of conventions used in ICD-9-CM to provide guidance to the coder, including instructional notations, punctuation marks, abbreviations, and symbols.

Instructional Notations Instructional notations are phrases or notes that appear in all three volumes of the code book and provide information related to code selection.

Coding Rule: The placement of the notation determines the code range that is governed by the notation. Coders must refer to the start of chapters, sections, categories, and the fourth- and fifth-digit levels to determine whether an instructional notation is present.

Includes: Instructional Notation The notation Includes:, also known as an inclusion note, is used to define and give examples of the content of the chapter, section, category, or subcategory code. (However, Includes: is not actually used at the subcategory level; instead, the code book simply lists the included terms.) Placement of the Includes: notation is important in determining the range of codes that the notation applies to.

Placement of Inclusion Note at Chapter Level At the beginning of chapter 1, “Infectious and Parasitic Diseases,” in the Tabular List of Diseases and Injuries of ICD-9-CM, the following inclusion note appears. Includes: diseases generally recognized as communicable or transmissible as well as a few diseases of unknown but possibly infectious origin.

Because the notation is placed at the beginning of the chapter, this note applies to the entire “Infectious and Parasitic Diseases” chapter.

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Placement of Inclusion Note at Section Level Placement of the inclusion note at the section level signifies that the note governs an entire section of codes. In chapter 1, “Infectious and Parasitic Diseases,” of the Tabular List of Diseases and Injuries of ICD-9-CM, an inclusion note appears after the start of the section entitled “Tuberculosis” (010–018). The inclusion note reads as follows: Includes: infection by Mycobacterium tuberculosis (human) (bovine)

The placement of this inclusion notation signifies that only the code range of 010–018 is governed by this note, not the rest of the chapter.

Placement of the Inclusion Note at the Category Code Level Inclusion notes are also placed at the category code level. In chapter 1, “Infectious and Parasitic Diseases,” of the Tabular List of Diseases and Injuries, category code 003 is found. The following inclusion note appears for category code 003: Includes: infection or food poisoning by Salmonella (any serotype)

The placement of this inclusion notation indicates that it applies only to category code range 003.0–003.9 because it is placed after the category code 003.

Placement of Inclusion Note at the Fourth- and Fifth-Digit Level At the fourth- and fifth-digit levels, the notation Includes: does not appear. However, within fourth- and fifth-digit levels, a listing of diagnoses contained within these levels appears. For example, in the listing of code 003.0, found in the Tabular List of Diseases and Injuries, the term Salmonellosis appears, indicating that this disease is classified to this code. The code 003.0 appears as follows: 003.0 Salmonella gastroenteritis Salmonellosis

Salmonellosis represents a diagnosis that is contained or included only in this fourth-digit level. As seen in the example at the fourth-digit level, the Includes: notation would also hold true at the fifth-digit level. The following is an example of an Includes: notation at the fifth-digit level. 008.41 Staphylococcus Staphylococcal enterocolitis

Exercise 4–1

Identifying Inclusion Notes

For each of the following items, list the diagnosis that is included, as described by the inclusion notation. The first one is completed for you. 1. Category code 070

Viral Hepatitis (Acute) (Chronic)

2. Code 065.8 3. Category code 244 4. Category code 458 5. Code 491.0 6. Section “Hernia of Abdominal Cavity” (550–553)

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Section I

Introduction to Coding

7. Code 372.73 8. Category code 800 9. Category code 710 10. Code 519.9 11. Section “Organic Psychotic Conditions” (290–294) 12. Code 600.11

Excludes: Instructional Notation The Excludes: notation, also known as the exclusion note, is used to signify that the conditions listed are not assigned to the chapter, section, category, or fourth- or fifth-digit code listed.

Placement at the Chapter Level In the Tabular List of Diseases and Injuries at the start of chapter 1, “Infectious and Parasitic Diseases,” an exclusion notation appears. The Excludes: note reads as follows: Excludes: acute respiratory infections (460–466) carrier or suspected carrier of infectious organism (V02.0–V02.9) certain localized infections influenza (487.0–487.8, 488.0–488.1)

If the diagnosis is acute respiratory infection, the Excludes: notation tells the coder that this diagnosis is not included in chapter 1 but that it is included in code range 460–466. Within the exclusion note, following the diagnosis excluded, a code or code range appears in parentheses. The coder should then reference the code or code range in the parentheses. The code in the parentheses is more representative of the diagnosis being coded. This is the code number to be used.

Coding Rule: The placement of the exclusion notation determines the code range that the note governs. Therefore, the coder must reference the start of the chapter, section, category, and fourth- or fifth-digit codes to determine whether exclusion notations are present.

See: Instructional Notation The notation of See: is used in the Alphabetic Index of ICD-9-CM and instructs the coder to crossreference the term or diagnosis that follows the notation. For example, in the Alphabetic Index the following appears for the entry of toxicemia. Toxicemia—see Toxemia

This notation instructs the coder to cross-reference the term toxemia in the Alphabetic Index to obtain the correct code.

See Category: Instructional Notation The See category: notation is also used as a cross-reference in the Alphabetic Index of ICD-9-CM. This notation signals the coder to reference a specific category in the Tabular List.

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EXAMPLE: In the Alphabetic Index for the term late effect(s), of phlebitis or thrombophlebitis of intracranial venous sinuses, the following appears: Late Effect(s) (of)—see also condition phlebitis or thrombophlebitis of intracranial venous sinuses (conditions classifiable to 325)—see category 326

The notation refers the coder to category 326 for the correct code assignment.

See Also: Instructional Notation This is the third of the cross-reference notations that uses the word see in the instructional notation. The See also: notation refers the coder to another location in the Alphabetic Index when the initial listing does not contain all the necessary information to select a code accurately. When coding a diagnosis of palsy of both arms, the coder references the following in the Alphabetic Index: Palsy (see also Paralysis) 344.9

Within the listing for palsy, there is no subterm for both arms; therefore, the coder must reference paralysis. When the term paralysis is cross-referenced, a subterm for both arms appears. The entry under paralysis appears as follows: Paralysis, paralytic arm 344.40 affecting dominant side 344.41 nondominant side 344.42 both 344.2

The coder uses the 344.2 code because it is the most specific code for the diagnosis.

Coding Rule: The coder must use the cross-reference to obtain the correct code if a subterm of the diagnosis is not listed. However, if a subterm is listed, the cross-reference does not have to be followed. EXAMPLE: When coding Bell’s palsy, the coder does not have to reference paralysis because Bell’s appears as a subterm of palsy. The entry appears as follows: Palsy (see also Paralysis) 344.9 atrophic diffuse 335.20 Bell’s 351.0 newborn 767.5

Code First Underlying Disease, Cause, or Condition: Instructional Notation The Code first underlying disease, cause, or condition notation appears in the Tabular List of ICD-9-CM and must always be followed because it instructs the coder to use an additional code to identify an underlying disease, cause, or condition that is present. Therefore, two codes are needed to fully code the diagnostic statement. The two codes must appear in the order stated. EXAMPLE: In coding the diagnostic statement of “retinal dystrophy” in cerebroretinal lipidosis, the coder First references the main term dystrophy. The following appears in the Alphabetic Index. Dystrophy Retina, retinal (hereditary) 362.70 in cerebroretinal lipidosis 330.1 [362.71]

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Section I

Introduction to Coding

When this code is verified in the Tabular List, code 330.1 is used to code the cerebral lipidosis. Because the code 362.71 appears in the Alphabetic Index, this code, which is the code for retinal dystrophy, must also be used. When the code is verified in the Tabular List, the entry appears as follows: 362.71 Retinal dystrophy in systemic or cerebroretinal lipidoses Code first underlying disease, as: cerebroretinal lipidoses (330.1) systemic lipidoses (272.7)

The presence of this notation instructs the coder to use both codes to fully identify the diagnosis being coded; code 330.1 should be sequenced first when the codes 330.1 and 362.71 are reported.

Use Additional Code: Instructional Notation The instructional notation Use additional code signals the coder to add a second code to fully code the diagnosis. The coder should assign the additional code if it further describes the diagnosis being coded. The second code should always be assigned to help further define the diagnosis or condition being coded. EXAMPLE: In the Tabular List, category code 292 has a notation that instructs the coder to use an additional code. The entry appears as follows: Includes: organic brain syndrome associated with consumption of drugs Use additional code for any associated drug dependence (304.0–304.9) Use additional E code to identify drug

This notation tells the coder that if a patient has a drug-induced mental disorder and any associated drug dependence, an additional code to identify the dependence should be assigned with a code for the drug-induced mental disorder. If the diagnosis to be coded is a paranoid state due to unspecified drug dependence, the codes assigned are 292.11 and 304.90.

Exercise 4–2

Identifying Notations

For each item listed, indicate the type of instructional notation found. The first one is done. 1. Start of chapter 1, “Infectious and Parasitic Diseases”

Includes and Excludes

2. Code 292.2 3. Section entitled “Other Psychoses” (295–299) 4. Code 420.0 5. Chondromatosis, as listed in the Alphabetic Index 6. Boil, as listed in the Alphabetic Index 7. Hematomyelitis, late effect, as it appears in the Alphabetic Index 8. Section entitled “Dorsopathies” (720–724) 9. Code 996.7 10. Category V74 11. Endopericarditis, as it appears in the Alphabetic Index 12. Os, uterus, as it appears in the Alphabetic Index

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Punctuation Marks It is important to understand the meaning of the punctuation marks used in the code book as ICD-9-CM defines them in a manner unique to this coding system.

Parentheses ( ) Parentheses are used in both the Tabular List and Alphabetical Index. Parentheses are used around terms that provide additional information about the main diagnostic term. The presence of the additional information contained within the parentheses does not affect the code assignment for the diagnostic statement being coded, but they help to explain further the diagnosis given by the physician or practitioner. The words contained in the parentheses are sometimes referred to as “nonessential modifiers.” EXAMPLE: In the Alphabetical Index, the term dermatitis is found as follows: Dermatitis (allergic) (contact) (occupational) (venenata) 692.9

The parentheses are used around explanatory terms of the main term of dermatitis. If a coder is coding the following diagnoses, the code 692.9 is assigned. Dermatitis Allergic dermatitis Contact dermatitis Occupational dermatitis Venenata dermatitis EXAMPLE: In the Tabular List, the code 692.3 appears as follows: 692.3

Due to drugs and medicines in contact with skin Dermatitis (allergic) (contact) due to: arnica fungicides iodine . . .

The use of the parentheses here is the same as in the Alphabetical Index. The presence or absence of the terms allergic or contact does not affect code assignment to this subcategory. Examples of some of the diagnoses coded to this subcategory are: Contact dermatitis due to iodine Allergic dermatitis due to iodine Dermatitis due to iodine Dermatitis due to fungicides

Square Brackets [ ] Square brackets are used only in the Tabular List. They enclose synonyms, alternative wording, abbreviations, or explanatory phrases. The presence or absence of the phrase in the bracket does not affect code assignment. EXAMPLE: Code 968.5 appears in the Tabular List as follows: 968.5 Surface [topical] and infiltration anesthetics Cocaine Procaine Lidocaine [lignocaine] Tetracaine

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Section I

Introduction to Coding

The term topical is enclosed in brackets to provide an alternative word for surface; and lignocaine is also enclosed in brackets because it is an alternative word for “lidocaine.” Therefore, this subcategory is used to code the diagnoses of poisoning by topical application of lidocaine or poisoning by lidocaine. The term topical does not have to be present to code to this subcategory. Square brackets are also used in some editions of ICD-9-CM to enclose fifth digits that are considered valid digits for a code. This use varies from publisher to publisher. To determine whether your code book has this feature, reference code 640.0. The digits 0, 1, and 3 should appear in square brackets if your book has this feature.

Italicized Brackets [ ] Italicized or slanted brackets are used in the Alphabetic Index to enclose a second code that must be assigned when coding. This is used to record the etiology and/or the manifestation of a disease. These codes should be reported to third-party payers in the order that the codes appear in the Alphabetic Index. EXAMPLE: In the Alphabetical Index, the term diabetic gangrene appears as follows: Diabetes, diabetic gangrene 250.7 [785.4]

To correctly code this diagnosis, the coder lists 250.7 first, to identify the unspecified type of diabetes, and code 785.4 second, to identify the gangrene. When verifying the codes in the Tabular List, the coder is instructed to use a second code by the presence of an instructional notation: “use additional code for any associated condition” or “use additional code to identify manifestation.” Therefore, the Alphabetic Index and Tabular List signal the coder to use two codes to record the diagnoses being coded.

Braces } Braces are used to connect a series of terms appearing on the left of the brace to a common term on the right of the brace. The terms on the left of the brace must be followed by the term on the right of the brace to be included in the code number being considered. EXAMPLE: Code 515 in the Tabular List appears as follows: 515

Postinflammatory pulmonary fibrosis Cirrhosis of lung Fibrosis of lung (atrophic) (confluent) (massive) (perialveolar) (peribronchial) Induration of lung

chronic or unspecified

The terms on the left must be followed by chronic or unspecified to be included in this category. It should be noted that some publishers of the code books do not use this convention.

Colon : The colon is used in the Tabular List after a term that is modified by one or more of the terms following the colon. The term on the left of the colon must be modified by a term on the right to be included in the code being considered. EXAMPLE: Code 291.5 appears in the Tabular List as follows: 291.5

Alcohol-induced psychotic disorder with delusions Alcoholic: paranoia psychosis, paranoid type

For a psychosis to be coded to this subcategory, it must be of an alcoholic nature and be paranoia or psychosis, paranoid type. If the diagnosis does not specify the terms to the right of the colon, it would not be included in this subcategory.

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Abbreviations Two abbreviations are consistently used in ICD-9-CM: NEC and NOS.

NEC (Not Elsewhere Classifiable) NEC means not elsewhere classifiable. There are two purposes for the abbreviation of NEC. First, it is used with poorly defined terms to warn the coder that specified forms of the diagnosis being coded are classified to different code numbers. The NEC code should only be used if more precise information is not available about the diagnosis. Second, the NEC code should be used when the Tabular List does not provide a separate code for the diagnosis being coded even though the diagnosis is very specific EXAMPLE: In coding the diagnosis of cervical syndrome of the spine, the coder first references the Alphabetical Index under the main term of syndrome. The following appears: Syndrome cervical (root) (spine) NEC 723.8 disc 722.71 posterior, sympathetic 723.2 rib 353.0 sympathetic paralysis 337.09 traumatic (acute) NEC 847.0

After reading through the subterms listed, the coder selects code 723.8 because the diagnosis does not give more specific information. This diagnosis is not elsewhere classified in ICD-9-CM to a specific code. To further complete the coding, the coder would reference code 723.8 in the Tabular List. Here again the abbreviation of NEC appears to signal the coder that a specific code for cervical syndrome is not present in the coding book. The entry in the Tabular List appears as follows: 723.8

Other syndromes affecting cervical region Cervical syndromes NEC Klippel’s disease Occipital neuralgia

NOS (Not Otherwise Specified) NOS is the abbreviation for not otherwise specified. It is also interpreted to mean unspecified. This is used only in the Tabular List. NOS codes are not specific and should be used only after the coder has clarified with the physician that a more specific diagnosis is not available. The coder should also reference the medical record to see whether it contains documentation that can further specify the diagnosis. EXAMPLE: A patient is seen, and the physician makes a diagnosis of sinusitis and orders a series of sinus X-rays. The physician records sinusitis on the coding form. The coder then references “sinusitis” in the Alphabetic Index and records code 473.9. However, at the time of coding the X-rays are completed and indicate that frontal sinusitis is present. The coder should then select code 473.1, which identifies frontal sinusitis. If there is no further documentation or findings, that is, no X-rays taken, to expand on the original diagnosis of sinusitis, then code 473.9 would be the correct code to assign. The entry in the Tabular List appears as follows: 473.9

Unspecified sinusitis (chronic) Sinusitis (chronic) NOS

The abbreviation of NOS should signal to the coder to try to clarify the diagnosis more specifically before assigning the code.

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Section I

Introduction to Coding

Symbols Section Mark Symbol § This symbol, §, appears before a code number and denotes the presence of a footnote. The coder should reference the footnote, because it contains additional information relevant to code selection. Footnotes are frequently used in chapter 11, “Complications of Pregnancy, Childbirth, and the Puerperium,” to instruct the coder that a fifth digit is needed for the code to be complete. The section mark is not used by all the companies that publish coding books.

Steps in Coding To accurately assign codes, the coder must understand the conventions that ICD-9-CM uses. Another equally important aspect of coding is having specific written diagnoses and procedures to code. If the diagnoses and procedures are not specifically recorded or recorded in one location in the record, it is necessary for the coder to completely review the record to select all diagnoses and procedures to be coded. Even if the diagnoses and procedures are located on one form in the record, coders should still review the record to obtain the most complete information. Diagnoses and procedures for inpatient records are typically recorded on a face sheet. In an outpatient setting, various forms are used to record the diagnosis and procedures completed. In a physician’s office, an encounter form or a problem list is used to record the diagnoses and procedures. When reviewing the record, the coder should note any procedures or tests that were ordered for which the results are not available at the time of coding. These test results could change the diagnosis, and therefore the coder should wait for the results of a test to determine the most accurate diagnosis to code. However, in some settings, such as a physician’s office, coders do not wait for all test results. Organizations establish coding policies to address this issue. For accurate coding to occur, the coder should follow these steps indicated: Step 1. Locate the main term in volume 2, “Alphabetic Index.” When coding a diagnosis, the coder first must select the main term of the diagnostic phrase that is being coded. For example, when coding the diagnostic phrase “chronic allergic sinusitis due to dust,” the main term to be located in the Alphabetic Index is sinusitis. (This example will be used to illustrate the steps in coding.) Remember that in the Alphabetic Index the primary arrangement of the diagnostic terms is by condition. When coding procedures in ICD-9-CM, the primary arrangement of terms in the Alphabetic Index of Procedures is by the name of the procedure. Step 2. Scan the main term entry for any instructional notations. After locating the main term in the Alphabetic Index, a coder should review the main term entry in the Alphabetic Index for any instructional notations that may appear. If a notation is present, follow it. There are no notations appearing with the diagnosis of sinusitis. (For an example of an instructional notation in the Alphabetic Index, turn to the entry “fracture.” Here a note appears.) Step 3. In the diagnostic phrase being coded, identify any terms that modify the main term. Terms that serve as modifiers in this example are chronic and allergic. Chronic appears in parentheses following the main term of sinusitis, and allergic appears as a subterm, indented under the main term. Step 4. Follow any cross-reference notations. Cross-references appear by the use of instructional notations such as see also and see. Next to the term allergic, the instructional notation of (see also Fever, hay) appears. The coder should follow this instruction. The coder should now reference “fever, hay” in the Alphabetic Index. The entry of “fever, hay” is further divided into subcategories for the cause of the allergy. The entry lists dust as the allergen; therefore the coder should select the code 477.8. Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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Step 5. Always verify the code in volume 1, “Tabular List of Diseases and Injuries.” After selecting a code from the Alphabetic Index, the coder must always verify the code in the Tabular List. Additional instructional notations can appear in the Tabular List that are not present in the Alphabetic Index. Step 6. Follow any instructional terms. After turning to the Tabular List, scan for any instructional terms that may be present. Coders should scan the following areas: a. The start of the chapter—Here instructional notations appear that govern the entire chapter. In the example of sinusitis, the coder scans the start of chapter 8, “Diseases of the Respiratory System.” Here a note appears that instructs the coder to “use additional code to identify infectious organism.” In our example, an infectious organism is not present. b. The beginning of the section range—In the example used, the section range is entitled “Other Diseases of the Upper Respiratory Tract” (470–478). Instructional notations that govern the section range appear here. In our example, no instructional notations appear at this level. c. At the beginning of the category, subcategory, or subclassification level—In our example, the following appears: 477 Allergic rhinitis Includes: allergic rhinitis (nonseasonal) (seasonal) hay fever spasmodic rhinorrhea Excludes: allergic rhinitis with asthma (bronchial) 493.0

The presence of the note assures the coder that the correct code is being selected. Step 7. Select the code. After completing these steps, the coder can now select the code. In addition, the coder should scan the code selected to ensure that the most specific code has been selected. If fourth and fifth digits are present, the coder must select the code to the highest degree of specificity. In our example, the category of 477, “Allergic rhinitis,” was divided into fourth-digit, subcategory levels. This is the most specific level that can be coded. However, if fifth-digit levels are present, they must be selected. The ICD-9-CM Official Guidelines for Coding and Reporting include the following guidelines that address conventions for ICD-9-CM.

Official ICD-9-CM Coding Guidelines: A. Conventions for the ICD-9-CM The conventions for the ICD-9-CM are the general rules for use of the classification independent of the guidelines. These conventions are incorporated within the index and tabular of the ICD-9-CM as instructional notes. The conventions are as follows: 1. Format: The ICD-9-CM uses an indented format for ease in reference 2. Abbreviations a. Index abbreviations NEC “Not elsewhere classifiable” This abbreviation in the index represents “other specified” when a specific code is not available for a condition the index directs the coder to the “other specified” code in the tabular. b. Tabular abbreviations NEC “Not elsewhere classifiable” This abbreviation in the tabular represents “other specified.” When a specific code is not available for a condition the tabular includes an NEC entry under a code to identify the code as the “other specified” code. (See Section I.A.5.a, “Other” codes.)

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Section I

Introduction to Coding

NOS “Not otherwise specified” This abbreviation is the equivalent of unspecified. (See Section I.A.5.b, “Unspecified” codes.) 3. Punctuation [ ] Brackets are used in the tabular list to enclose synonyms, alternative wording or explanatory phrases. Brackets are used in the index to identify manifestation codes. (See Section I.A.6, “Etiology/manifestations.”) ( ) Parentheses are used in both the index and tabular to enclose supplementary words that may be present or absent in the statement of a disease or procedure without affecting the code number to which it is assigned. The terms within the parentheses are referred to as nonessential modifiers. : Colons are used in the Tabular list after an incomplete term which needs one or more of the modifiers following the colon to make it assignable to a given category. 4. Includes and Excludes Notes and Inclusion Terms Includes: This note appears immediately under a three-digit code title to further define, or give examples of, the content of the category. Excludes: An excludes note under a code indicates that the terms excluded from the code are to be coded elsewhere. In some cases the codes for the excluded terms should not be used in conjunction with the code from which it is excluded. An example of this is a congenital condition excluded from an acquired form of the same condition. The congenital and acquired codes should not be used together. In other cases, the excluded terms may be used together with an excluded code. An example of this is when fractures of different bones are coded to different codes. Both codes may be used together if both types of fractures are present. Inclusion terms: List of terms is included under certain four and five digit codes. These terms are the conditions for which that code number is to be used. The terms may be synonyms of the code title, or, in the case of “other specified” codes, the terms are a list of the various conditions assigned to that code. The inclusion terms are not necessarily exhaustive. Additional terms found only in the index may also be assigned to a code. 5. Other and Unspecified codes a. “Other” codes Codes titled “other” or “other specified” (usually a code with a 4th digit 8 or fifth-digit 9 for diagnosis codes) are for use when the information in the medical record provides detail for which a specific code does not exist. Index entries with NEC in the line designate “other” codes in the tabular. These index entries represent specific disease entities for which no specific code exists so the term is included within an “other” code. b. “Unspecified” codes Codes (usually a code with a 4th digit 9 or 5th digit 0 for diagnosis codes) titled “unspecified” are for use when the information in the medical record is insufficient to assign a more specific code. 6. Etiology/manifestation convention (“code first,” “use additional code,” and “in diseases classified elsewhere” notes) Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD-9-CM has a coding convention that requires the underlying condition be sequenced first followed by the manifestation. Wherever such a combination exists, there is a “use additional code” note at the etiology code, and a “code first” note at the manifestation code. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation. In most cases the manifestation codes will have in the code title, “in diseases classified elsewhere.” Codes with this title are a component of the etiology/manifestation convention. The code title indicates that it is a manifestation code. “In diseases classified elsewhere” codes are never permitted to be used as first listed or principal diagnosis codes. They must be used in conjunction with an underlying condition code and they must be listed following the underlying condition. There are manifestation codes that do not have “in diseases classified elsewhere” in the title. For such codes a “use additional code” note will still be present and the rules for sequencing apply. In addition to the notes in the tabular, these conditions also have a specific index entry structure. In the index both conditions are listed together with the etiology code first followed by the manifestation codes in brackets. The code in brackets is always to be sequenced second.

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ICD-9-CM Coding Conventions and Steps in Coding

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The most commonly used etiology/manifestation combinations are the codes for Diabetes mellitus, category 250. For each code under category 250 there is a use additional code note for the manifestation that is specific for that particular diabetic manifestation. Should a patient have more than one manifestation of diabetes, more than one code from category 250 may be used with as many manifestation codes as are needed to fully describe the patient’s complete diabetic condition. The category 250 diabetes codes should be sequenced first, followed by the manifestation codes. “Code first” and “Use additional code” notes are also used as sequencing rules in the classification for certain codes that are not part of an etiology/ manifestation combination. See Section I.B.9, “Multiple coding for a single condition.” 7. “And” The word “and” should be interpreted to mean either “and” or “or” when it appears in a title. 8. “With” The word “with” should be interpreted to mean “associated with” or “due to” when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List. 9. “See” and “See Also” The “see” instruction following a main term in the index indicates that another term should be referenced. It is necessary to go to the main term referenced with the “see” note to locate the correct code. A “see also” instruction following a main term in the index instructs that there is another main term that may also be referenced that may provide additional index entries that may be useful. It is not necessary to follow the “see also” note when the original main term provides the necessary code. B. General Coding Guidelines 1. Use of Both Alphabetic Index and Tabular List Use both the Alphabetic Index and the Tabular List when locating and assigning a code. Reliance on only the Alphabetic Index or the Tabular List leads to errors in code assignments and less specificity in code selection. 2. Locate each term in the Alphabetic Index Locate each term in the Alphabetic Index and verify the code selected in the Tabular List. Read and be guided by instructional notations that appear in both the Alphabetic Index and the Tabular List. 3. Level of Detail in Coding Diagnosis and procedure codes are to be used at their highest number of digits available. ICD-9-CM diagnosis codes are composed of codes with 3, 4, or 5 digits. Codes with three digits are included in ICD-9-CM as the heading of a category of codes that may be further subdivided by the use of fourth and/or fifth digits, which provide greater detail. A three-digit code is to be used only if it is not further subdivided. Where fourth-digit subcategories and/or fifth-digit subclassifications are provided, they must be assigned. A code is invalid if it has not been coded to the full number of digits required for that code. For example, Acute myocardial infarction, code 410, has fourth digits that describe the location of the infarction (e.g., 410.2, Of inferolateral wall), and fifth digits that identify the episode of care. It would be incorrect to report a code in category 410 without a fourth and fifth digit. ICD-9-CM Volume 3 procedure codes are composed of codes with either 3 or 4 digits. Codes with two digits are included in ICD-9-CM as the heading of a category of codes that may be further subdivided by the use of third and/or fourth digits, which provide greater detail. 4. Code or codes from 001.0 through V89.09 The appropriate code or codes from 001.0 through V89.09 must be used to identify diagnoses, symptoms, conditions, problems, complaints, or other reason(s) for the encounter/visit. 5. Selection of codes 001.0 through 999.9 The selection of codes 001.0 through 999.9 will frequently be used to describe the reason for the admission/ encounter. These codes are from the section of ICD-9-CM for the classification of diseases and injuries (e.g., infectious and parasitic diseases; neoplasms; symptoms, signs, and ill-defined conditions, etc.).

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Section I

Introduction to Coding

Summary • ICD-9-CM uses a group of instructional notations, abbreviations, punctuation marks, and symbols to guide the coder. • An Includes: note gives examples of the content of a section of the code book. • An Excludes: note indicates terms that are excluded from a section of the code book. • NEC means not elsewhere classifiable. • NOS means not otherwise specified. • Brackets are used to enclose synonyms, alterative wording, or explanatory phrases. • Parentheses are used to enclose supplementary words. • Colons are used after an incomplete term to identify one or more modifiers. • The phrases code first and use additional code notes are used to identify sequencing of codes. • The Alphabetic Index and the Tabular List must both be used when assigning codes. • All instructional notations that appear in the Alphabetic Index and the Tabular List should be read and used as a guide when selecting codes.

Chapter Review True/False: Indicate whether each statement is true (T) or false (F). 1.

NEC means not elsewhere coded.

2.

Terms that appear in parentheses must appear in the diagnostic statement being coded.

3.

NOS means not otherwise specified.

4.

The placement of an inclusion note signifies the section of the code book that the note governs.

5.

At the fourth- and fifth-digit levels, the notation Includes: does not appear; however, a listing of diagnoses contained within these levels appears.

6.

NOS is used with poorly defined terms to warn the coder that specified forms of the diagnosis being coded are classified to different code numbers.

7.

The See also: notation refers the coder to another location in the Tabular List.

8.

At times, two codes are used to code a diagnostic statement.

9.

In the diagnostic phrase “acute frontal sinusitis,” the main term to reference in the Alphabetic Index is frontal.

10.

The first step in coding is to locate the main term in the Tabular List.

Short Answer: For each diagnostic or procedural statement listed, identify the main term that would be used in the Alphabetic Index of ICD-9-CM. 11.

Unstable angina

12.

Congestive heart failure

13.

Acute punctured eardrum

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14.

Repair of fracture

15.

Excision of lesion

16.

Ulcerative chronic tonsillitis

17.

Chronic left quadrant abdominal pain

18.

Gastritis due to diet deficiency

19.

Primary neoplasm of stomach

20.

Abscess of vas deferens

21.

Release of carpal tunnel

22.

Streptococcal peritonitis

23.

Ileo-jejunal bypass

24.

Ulcer with gangrene

25.

Reconstruction of eye socket

26.

Acute broncholitis

27.

Tarsal synostosis

28.

Congenital nipple retraction

29.

Postsurgical lordosis

30.

Open Wound

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Short Answer: Briefly respond to the following. 31.

List the steps in coding.

32.

Differentiate between the abbreviations NOS and NEC.

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Section I

Introduction to Coding

33.

Explain why coders must reference both the Alphabetic Index and Tabular List.

34.

Explain what a nonessential modifier is.

35.

Explain why it is important that all instructional notations are followed.

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CHAPT ER

Coding Guidelines

5

Chapter Outline Introduction Section I—ICD-9-CM Conventions, General Coding Guidelines, and Chapter-Specific Guidelines Section II—Selection of Principal Diagnosis Section III—Reporting Additional Diagnoses Section IV—Diagnostic Coding and Reporting Guidelines for Outpatient Services

Appendix I of the ICD-9-CM Official Guidelines for Coding and Reporting— Present on Admission Reporting Guidelines Internet Links Summary Chapter Review

Objectives At 1. 2. 3. 4.

the conclusion of this chapter, the student will be able to: List the Cooperating Parties for ICD-9-CM. Explain the purpose of the ICD-9-CM Official Guidelines for Coding and Reporting. Identify the four sections of the ICD-9-CM Official Guidelines for Coding and Reporting. Differentiate and explain the guidelines for inpatient versus outpatient and physician office visits. 5. Summarize the guidelines for the sequencing of diagnostic codes. 6. Explain the purpose of the Present on Admission Guidelines.

Key Terms Appendix I—Present on Admission Reporting Guidelines

Combination Code Cooperating Parties for ICD-9-CM

ICD-9-CM Official Guidelines for Coding and Reporting

Late Effect POA Indicator

Reminder As you work through this chapter, you will need to reference the ICD-9-CM Official Guidelines for Coding and Reporting. These guidelines can be found in Appendix A of this book.

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Section I

Introduction to Coding

Principal Diagnosis Secondary Diagnosis

Section I—Conventions, General Coding Guidelines, and Chapter-Specific Guidelines

Section II—Selection of Principal Diagnosis Section III—Reporting Additional Diagnoses

Section IV—Diagnostic Coding and Reporting Guidelines for Outpatient Services

Introduction To ensure accurate diagnostic and procedural information, ICD-9-CM is used to capture information for third-party reimbursement, continuity of patient care, healthcare statistics, and other reporting functions. In an effort to assist coders in consistently using ICD-9-CM, the ICD-9-CM Official Guidelines for Coding and Reporting were developed by the Cooperating Parties for ICD-9-CM. The Cooperating Parties for ICD-9-CM included the following organizations: • American Hospital Association • American Health Information Management Association • Centers for Medicare and Medicaid Services (CMS) • National Center for Health Statistics (NCHS) These parties cooperatively developed and approved the ICD-9-CM Official Guidelines for Coding and Reporting for publication by the Department of Health and Human Services. The guidelines are organized into four sections with one appendix, as follows: • Section I—Conventions, General Coding Guidelines, and Chapter-Specific Guidelines. In this section the guidelines address the structure and conventions of ICD-9-CM and provide general guidelines that apply to the entire classification, as well as chapter-specific guidelines. • Section II—Selection of Principal Diagnosis. This section includes guidelines for the selection of principal diagnosis for nonoutpatient settings. Nonoutpatient settings include acute care, shortterm care, long-term care, and psychiatric hospitals; home health agencies; rehab facilities; nursing homes; and the like. • Section III—Reporting Additional Diagnoses. In this section the guidelines cover the reporting of additional diagnoses that affect patient care in nonoutpatient settings. • Section IV—Diagnostic Coding and Reporting Guidelines for Outpatient Services. This section outlines the guidelines for outpatient coding and reporting. These coding guidelines for outpatient diagnoses have been approved for use by hospitals and providers in coding and reporting hospitalbased outpatient services and provider-based office visits. • Appendix I—Present on Admission Reporting Guidelines. Effective October 1, 2007, CMS required that for all Medicare inpatient acute care discharges, facilities must report all diagnoses and external cause of injury codes that are present on admission of the patient. This appendix outlines the guidelines for implementation of the present on admission indicators.

Section I—ICD-9-CM Conventions, General Coding Guidelines, and Chapter-Specific Guidelines Section I provides guidelines for conventions as well as general coding guidelines and chapter-specific guidelines. The guidelines for conventions were previously reviewed in Chapter 4 of this book. The general coding guidelines will be reviewed in this chapter, and the chapter-specific guidelines will be reviewed in the remaining chapters of this book. The chapter-specific guidelines are sequenced in the

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Official Guidelines in the same order as they appear in the ICD-9-CM Tabular List. For example, chapter 1 of the ICD-9-CM Tabular List is entitled “Infectious and Parasitic Diseases,” and the first subsection in the chapter-specific guidelines is C1, entitled “Chapter 1: Infectious and Parasitic Diseases (001–139).” Numerous guidelines have been used in the development of this book and appear throughout the book in the highlighted Coding Guideline areas. However, all coders need to read and become familiar with all of the Official Guidelines to enhance coding accuracy. (Author Bowie encourages her new coding students to read the Official Guidelines from front to back numerous times! She thinks of the guidelines as the directions for the ingredients when baking. If you don’t follow the directions when baking, your cake will not turn out as it should. If you don’t follow the coding guidelines, you will not select the proper codes. Coding is also like baking: the more you bake, the better baker you become. The more you code, the better coder you become!)

Acute and Chronic Conditions This guideline is used when coding the diagnostic statement “acute and chronic bronchitis.” Both codes 466.0, Acute bronchitis, and 491.9, Chronic bronchitis, are assigned, with 466.0 sequenced first. To assign both codes, the medical documentation must clearly document both the acute and chronic condition. If both terms do not appear in the patient’s record, then only one code should be used as documented in the record, or the physician should be asked for clarification.

Official ICD-9-CM Coding Guideline: If the same condition is described as both acute (subacute) and chronic, and separate subentries exist in the Alphabetic Index at the same indentation level, code both and sequence the acute (subacute) code first. (See Appendix A, Section I, B10.)

Combination Code Official ICD-9-CM Coding Guideline: A combination code is a single code used to classify two diagnoses, a diagnosis with an associated secondary process (manifestation), or a diagnosis with an associated complication. Combination codes are identified by referring to subterm entries in the Alphabetic Index and by reading the inclusion and exclusion notes in the Tabular List. Assign only the combination code when that code fully identifies the diagnostic conditions involved or when the Alphabetic Index so directs. Multiple coding should not be used when the classification provides a combination code that clearly identifies all of the elements documented in the diagnosis. When the combination code lacks necessary specificity in describing the manifestation or complication, an additional code should be used as a secondary code. (See Appendix A, Section I, B11.) An example of a combination code occurs when the diagnostic phrase “acute appendicitis with generalized peritonitis” is coded. In this example two diagnoses are present: acute appendicitis and generalized peritonitis. When the Alphabetic Index is referenced for appendicitis, the following appears: Appendicitis 541 with perforation, peritonitis (generalized), or rupture 540.0 with peritoneal abscess 540.1 peritoneal abscess 540.1 . . .

This signifies that one code is to be used to code both diagnoses.

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Section I

Introduction to Coding

Codes That Describe Symptoms and Signs Official ICD-9-CM Coding Guideline: Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider. Chapter 16 of ICD-9-CM, “Symptoms, Signs, and Ill-Defined Conditions” (codes 780.0–799.9) contain many, but not all codes for symptoms. (See Appendix A, Section I, B6.) Codes that describe symptoms and signs, such as pain and fever, are acceptable for coding when a definitive diagnosis has not been established. For example, when a patient presents in a physician’s office for abdominal pain and the cause has not been confirmed, the abdominal pain is coded.

Conditions That Are an Integral Part of a Disease Process Official ICD-9-CM Coding Guideline: Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification. (See Appendix A, Section I, B7.) When a definitive diagnosis is recorded and signs and symptoms are recorded, the coder should code the definitive diagnosis only if the signs and symptoms are integral to the disease process. Symptoms such as cough and fever are not recorded for a patient who has been diagnosed with a respiratory infection.

Conditions That Are Not an Integral Part of a Disease Process Official ICD-9-CM Coding Guideline: Additional signs and symptoms that may not be associated routinely with a disease process should be coded when present. (See Appendix A, Section I, B8.) If signs and symptoms exist that are not routinely associated with a disease process, the signs and symptoms should be coded. If a patient presents for a sprained ankle and is also experiencing vomiting, both the ankle sprain and the symptom of vomiting are recorded.

Multiple Coding for a Single Condition Official ICD-9-CM Coding Guideline: In addition to the etiology/manifestation convention that requires two codes to fully describe a single condition that affects multiple body systems, there are other single conditions that also require more than one code. “Use additional code” notes are found in the tabular at codes that are not part of an etiology/manifestation pair where a secondary code is useful to fully describe a condition. The sequencing rule is the same as for the etiology/manifestation pair; “use additional code” indicates that a secondary code should be added. (See Appendix A, Section I, B, 9.) As described in Chapter 4, there are conventions that instruct coders to assign multiple codes to a single condition. These conventions include the instruction notations of Use additional code and Code first underlying condition. Because these conventions are commonly used with codes for infectious diseases, they will be discussed in greater detail in Chapter 6 of this book. Multiple codes are also used

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for late effects, complication codes, and obstetric codes. These will also be described in their respective chapters.

Impending or Threatened Conditions Official ICD-9-CM Coding Guideline: Code any condition described at the time of discharge as “impending” or “threatened” as follows: If it did occur, code as confirmed diagnosis. If it did not occur, reference the Alphabetic Index to determine if the condition has a subentry term for “impending” or “threatened” and also reference main term entries for “Impending” and “Threatened.” If the subterms are listed, assign the given code. If the subterms are not listed, code the existing underlying condition(s) and not the condition described as impending or threatened. (See Appendix A, Section I, B13.) To accurately code a diagnosis that is modified by the terms impending or threatened, the coder must answer the question “did the condition actually occur?” If the condition occurred, then code the diagnosis as confirmed. For example, if a physician recorded “impending rupture of spleen due to enlarged spleen” and the spleen ruptured, then the diagnostic statement of ruptured spleen is coded by using code 289.59. If the condition did not occur, the coder needs to reference the Alphabetic Index to determine whether the condition has a subentry term for “impending” or “threatened” and also reference main term entries for “impending” and “threatened.” For example, if a physician recorded the diagnostic statement of “impending rupture of spleen due to enlarged spleen” but treatment prevented the rupture, the code for enlarged spleen, 789.2, is recorded, because there is no code for the impending rupture of spleen in the main term entries in the Alphabetic Index. At times, ICD-9-CM does use the terms impending or threatened in the Alphabetic Index. When the condition does not occur, but the terms impending or threatened are used in the diagnostic statement and ICD-9-CM provides a main term entry or subterm entry of impending or threatened, the code is assigned that appears in the Alphabetic Index. EXAMPLE: A physician records the diagnostic statement of “threatened miscarriage,” but the miscarriage does not occur. Because ICD-9-CM provides an entry in the Alphabetic Index for “threatened miscarriage,” code 640.0X is assigned.

Late Effects Official ICD-9-CM Coding Guideline: A late effect is the residual effect (condition produced) after the acute phase of an illness or injury has terminated. There is no time limit on when a late effect code can be used. The residual may be apparent early, such as in cerebrovascular accident cases, or it may occur months or years later, such as that due to a previous injury. Coding of late effects generally requires two codes sequenced in the following order: The condition or nature of the late effect is sequenced first. The late effect code is sequenced second. An exception to these guidelines are instances where the code for late effect is followed by a manifestation code identified in the Tabular List and title or where the late effect code has been expanded (at the fourth- and fifth-digit levels) to include the manifestation(s). The code for the acute phase of an illness or injury that led to the late effect is never used with a code for the late effect. (See Appendix A, Section I, B 12.)

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Section I

Introduction to Coding

A physician records the diagnostic phrase “malunion of fracture of left tibia.” The malunion is the residual condition that was caused by the fracture, known as the late effect. Common terms that are used to describe residual conditions include: Due to old illness or injury Due to previous illness or injury Following previous illness or injury Late Malunion Nonunion Old Scarring Secondary to illness or injury in previous time Sequela of

When these terms are used, the coder can assume that a late effect exists. To code late effects, the coder should reference the main term of late in the Alphabetic Index. Here a subterm effects also appears. It should be noted that two codes are needed to code late effects: One code is used to code the residual condition, and one code is used to code the cause of the late effect. The code for the residual condition is listed first, followed by the code for the cause. (There are some exceptions to this, and the coder should be guided by instructions found in the Alphabetic Index and Tabular List.) EXAMPLE: Sally Smith is a patient at Sunny View Nursing Home who has been admitted with the following diagnosis: traumatic arthritis due to old fracture of left ankle. This would be coded to 716.17, coding traumatic arthritis, and 905.4, coding the cause of the arthritis. The coder first references the Alphabetic Index for the main term of arthritis and the subterm traumatic. Code 716.1x appears. (The x indicates that a fifth digit is needed for the code to be valid.) To code the cause of the arthritis, the coder then references the main term of Late in the Alphabetic Index, followed by the subterms of effects, fractures, extremity, lower. Code 905.4 appears, which codes late effect of fracture of lower extremities.

Exercise 5–1

Identifying Late Effects

For each of the following diagnostic statements, identify the residual condition and the late effect or cause of the residual. Diagnostic Statement 1. Paralysis due to old cerebrovascular accident 2. Mental retardation due to brain injury 3. Blindness due to chicken pox

Residual Condition

Late Effect or Cause

4. Scarring due to third-degree burns 5. Kyphosis due to poliomyelitis 6. Past history of polio patient now presents with scoliosis 7. Hemiplegia resulting from spinal cord injury that occurred five years ago

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Diagnostic Statement Residual Condition 8. Grand mal seizure due to encephalitis three years ago 9. Neural deafness caused by childhood measles 15 years ago 10. Malunion of spinal fracture

Coding Guidelines

65

Late Effect or Cause

Exceptions for Code Assignment for Late Effects As previously discussed, most coding of late effects requires two codes, with the residual condition sequenced first, followed by the cause of the late effect. However, the following exceptions exist: 1. A second code is not needed when medical documentation does not identify the residual. If a physician records “late effect of injury to hand,” only the code for the late effect is used. 2. Sequencing is reversed if the Alphabetic Index indicates a different sequence. For example, in coding scoliosis due to poliomyelitis, coders are instructed to first list code 138, the late effect code, followed by the code 737.43. 3. Only one code is needed if ICD-9-CM does not provide a code to describe the cause of the late effect. 4. Only one code is needed when the late effect code has been expanded at the fourth- and fifth-digit level to code both the late effect and residual. The only category code that this occurs with is code 438, Late effect of cerebrovascular disease.

Exercise 5–2

Coding Late Effects

For each of the following diagnostic statements, select the appropriate ICD-9-CM code(s). 1. Kyphosis due to polio 2. Ataxia due to cerebrovascular accident 3. Scarring of leg due to multiple lacerations from motor vehicle accident 4. Aphasia from previous cerebrovascular disease 5. Late effect of burn on face 6. Mental retardation due to viral encephalitis 7. Contracture of ankle due to previous fracture 8. Paralysis of right arm due to poliomyelitis 9. Scoliosis due to polio at age nine 10. Residuals of poliomyelitis

Chapter-Specific Coding Guidelines The Official ICD-9-CM Guidelines for Coding and Reporting outline the chapter-specific coding guidelines in Section I, C. These guidelines are for specific diagnoses and complications found in ICD-9-CM. These chapter-specific guidelines will be discussed throughout the remaining chapters of this book. Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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Section I

Introduction to Coding

Section II—Selection of Principal Diagnosis Section II of the ICD-9-CM Official Guidelines for Coding and Reporting is entitled “Section II— Selection of Principal Diagnosis.” This section of the guidelines is used to provide consistency in selecting the principal diagnosis, which is defined in the Uniform Hospital Discharge Data Set (UHDDS) as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.” The UHDDS definitions are used by hospitals to report inpatient data elements in a consistent, standardized manner. To review the definitions and the data elements that the definitions apply to, review the July 31, 1985, Federal Register (Vol. 50, No, 147), pp. 31038–40. It should be noted that the guidelines in this section are for all nonoutpatient settings (acute care; short-term care, long-term care, and psychiatric hospitals; home health agencies; rehab facilities; nursing homes; and the like). The guidelines for coding and reporting outpatient services, which include hospital-based outpatient services and physician office visits, are outlined in section IV of the ICD-9-CM Official Guidelines for Coding and Reporting.

Codes for Symptoms, Signs, and III-Defined Conditions Codes from chapter 16 of ICD-9-CM, “Symptoms, Signs, and Ill-Defined Conditions,” are not to be used as a principal diagnosis when a related definitive diagnosis has been established. EXAMPLE: A patient is admitted because of severe abdominal pain. After diagnostic testing, it was determined that the patient has a gastric ulcer. The gastric ulcer is the principal diagnosis.

Two or More Interrelated Conditions that Equally Meet the Definition for Principal Diagnosis When two or more interrelated conditions equally meet the definition for principal diagnosis, the guidelines state that any one of the diagnoses may be sequenced first. EXAMPLE: Tom Pick was admitted due to severe vomiting, nausea, and abdominal pain. After study it has determined that he had a gastric ulcer and diverticulitis. Treatment was equally directed at both diagnoses, and the physician documents that both conditions prompted the admission. Either condition could be listed as the principal diagnosis.

Two or More Comparative or Contrasting Conditions At times physicians record comparative or contrasting diagnoses by using the terms either or versus. The coding guideline states the following:

Official ICD-9-CM Coding Guideline: In those rare instances when two or more comparative or contrasting diagnoses are documented as “either/or” (or similar terminology), they are coded as if the diagnoses were confirmed and the diagnoses are sequenced according to the circumstances of the admission. If no further determination can be made as to which diagnosis should be principal, either diagnosis may be sequenced first. (See Appendix A, Section II, D.) EXAMPLE: Two comparative diagnoses, appendicitis versus diverticulitis, were recorded as the final diagnoses. The patient’s symptoms were controlled, and he was discharged. In this case either could be assigned as the principal diagnosis.

Symptom(s) Followed by Contrasting or Comparative Diagnoses At the time of discharge, physicians may not be able to distinguish a definitive diagnosis and may record a symptom, followed by contrasting or comparative diagnoses. The guidelines instruct coders to sequence these cases as follows:

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Official ICD-9-CM Coding Guideline: When a symptom(s) is followed by contrasting/comparative diagnoses, the symptom code is sequenced first. All the contrasting/comparative diagnoses should be coded as additional diagnoses. (See Appendix A, Section II, E.)

Original Treatment Plan Not Carried Out When treatment is not carried out, the coder must still answer the question “what diagnosis, after study, occasioned the admission to the hospital?” The principal diagnosis remains the same even if the treatment was not carried out.

Official ICD-9-CM Coding Guideline: Sequence as the principal diagnosis the condition, which after study occasioned the admission to the hospital, even though treatment may not have been carried out due to unforeseen circumstances. (See Appendix A, Section II, F.) EXAMPLE: Denny Sams is an 80-year-old man with a past history of gastric ulcer. He was admitted because of severe abdominal pain and back pain. After diagnostic study it was determined that he had kidney stones, and lithotripsy was planned. Before the lithotripsy, he was discharged at his request because he felt he needed to go home to care for his wife. The procedure was not performed. In this example the kidney stones are the reason for the admission and are therefore reported as the principal diagnosis.

Complications of Surgery and Other Medical Care Complications may result after surgery or from other medical care. In these cases the complication is considered the principal diagnosis.

Official ICD-9-CM Coding Guideline: When the admission is for treatment of a complication resulting from surgery or other medical care, the complication code is sequenced as the principal diagnosis. If the complication is classified to the 996–999 series and the code lacks the necessary specificity in describing the complication, an additional code for the specific complication may be assigned. (See Appendix A, Section II, G.)

Uncertain Diagnosis At times a physician does not have sufficient knowledge to make a definitive diagnosis at the time of discharge. In these cases the physician commonly records the diagnosis as questionable or suspected. In these cases the following guideline should be followed.

Official ICD-9-CM Coding Guideline: If the diagnosis documented at the time of discharge is qualified as “probable,” “suspected,” “likely,” “questionable,” “possible,” or “still to be ruled out,” or other similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis. (See Appendix A, Section II, H.) It should be noted that this guideline is relevant only to the selection of a principal diagnosis for inpatient admissions to short-term, acute, or long-term care, and psychiatric hospitals. This guideline is

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Introduction to Coding

not used for outpatient hospital records or physician office records. This will be discussed further later in this chapter under diagnostic coding and reporting guidelines for outpatient services.

Admission from Observation Unit or Outpatient Surgery At times patients are admitted as inpatients following medical observation, for postoperative observation following outpatient surgery, or for continuing inpatient care following outpatient surgery. The ICD-9-CM Official Guidelines for Coding and Reporting direct coders to select the principal diagnosis for these cases based on the following guidelines.

Official ICD-9-CM Coding Guideline: I. Admission from Observation Unit 1. Admission Following Medical Observation When a patient is admitted to an observation unit for a medical condition, which either worsens or does not improve, and is subsequently admitted as an inpatient of the same hospital for this same medical condition, the principal diagnosis would be the medical condition which led to the hospital admission. 2. Admission Following Post-Operative Observation When a patient is admitted to an observation unit to monitor a condition (or complication) that develops following outpatient surgery, and then is subsequently admitted as an inpatient of the same hospital, hospitals should apply the Uniform Hospital Discharge Data Set (UHDDS) definition of principal diagnosis as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.” J. Admission from Outpatient Surgery When a patient receives surgery in the hospital’s outpatient surgery department and is subsequently admitted for continuing inpatient care at the same hospital, the following guidelines should be followed in selecting the principal diagnosis for the inpatient admission: •• If the reason for the inpatient admission is a complication, assign the complication as the principal diagnosis. • If no complication, or other condition, is documented as the reason for the inpatient admission, assign the reason for the outpatient surgery as the principal diagnosis. • If the reason for the inpatient admission is another condition unrelated to the surgery, assign the unrelated condition as the principal diagnosis. (See Appendix A, Section II, I-J.) EXAMPLE: Tom Smith was placed in observation due to extreme renal colic. He was admitted because it was determined that he had kidney stones that were not going to pass. Surgery was completed to remove the kidney stones. The principal diagnosis for the admission is the kidney stones.

Section III—Reporting Additional Diagnoses In additional to the principal diagnosis, additional diagnoses are coded and reported. UHDDS defines other diagnoses, commonly called secondary diagnoses, as “all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or length of stay. Diagnoses that relate to an earlier episode which have no bearing on the current hospital stay are to be excluded.” This definition is used for inpatients in acute care, short-term care, long-term care, and psychiatric hospitals, home health agencies, rehab facilities, nursing homes, and the like to standardize reporting.

Previous Conditions Most facilities establish written policies for the coding of previous conditions. The Official Coding Guidelines states the following, which can be used as a basis for facility policy:

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Official ICD-9-CM Coding Guideline: If the provider has included a diagnosis in the final diagnostic statement, such as the discharge summary or the face sheet, it should ordinarily be coded. Some providers include in the diagnostic statement resolved conditions or diagnoses and status-post procedures from previous admission that have no bearing on the current stay. Such conditions are not to be reported and are coded only if required by hospital policy. However, history codes (V10−V19) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment. (See Appendix A, Section III, A.) EXAMPLE: Polly Jones was admitted because of severe headaches, nausea, weight loss, and dehydration. Four years ago she was treated for cancer of colon, which was resected; she has been in remission. The physician recorded dehydration as the principal diagnosis and history of cancer of the colon at time of discharge. History of cancer of colon is coded as a secondary diagnosis.

Abnormal Findings Abnormal findings are not coded and reported for inpatients unless the physician documents the significance of the findings.

Official ICD-9-CM Coding Guideline: Abnormal findings (laboratory, X-ray, pathologic, and other diagnostic results) are not coded and reported unless the provider indicates their clinical significance. If the findings are outside the normal range and the attending provider has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the provider whether the abnormal finding should be coded. Please note: This differs from the coding practices in the outpatient setting for coding encounters for diagnostic tests that have been interpreted by a provider. (See Appendix A, Section III, B.)

Uncertain Diagnosis If at the time of discharge the diagnosis documented is qualified, the condition should be coded as if it existed.

Official ICD-9-CM Coding Guideline: If the diagnosis documented at the time of discharge is qualified as “probable,” “suspected,” “likely,” “questionable,” “possible,” or “still to be ruled out,” or other similar terms indicating uncertainty, code the condition as if it existed or was established. (See Appendix A, Section III, C.) EXAMPLE: Tim Mack is admitted to Hill Hospital for abdominal cramping, fever, rectal pressure, and pain that have been present for the past five days. After admission he develops episodes of bloody diarrhea and an urgency to defecate. The physician records suspected ulcerative colitis at the time of discharge. Code 556.9 is assigned for this case.

Section IV—Diagnostic Coding and Reporting Guidelines for Outpatient Services Section IV of the ICD-9-CM Official Guidelines for Coding and Reporting is approved for use by hospitals and providers for reporting hospital-based outpatient services and provider-based office visits. It is important to note that the guidelines just discussed differ at times from the guidelines for outpatient and provider-based office visits. In the outpatient or office setting, the definition of principal diagnosis does not apply. In the outpatient setting, the term first-listed diagnosis is used.

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First-Listed Diagnosis Official ICD-9-CM Coding Guideline: In the outpatient setting, the term first-listed diagnosis is used in lieu of principal diagnosis. In determining the first-listed diagnosis, the coding conventions of ICD-9-CM, as well as the general and diseasespecific guidelines take precedence over the outpatient guidelines. Diagnoses often are not established at the time of the initial encounter/visit. It may take two or more visits before the diagnosis is confirmed. (See Appendix A, Section IV, A.) Because providers are often not able to establish a definitive diagnosis at the time of initial or subsequent visits, outpatient and physician office coders use codes from chapter 16 of ICD-9-CM, “Symptoms, Signs, and Ill-Defined Conditions,” as well as other symptom codes from disease chapters. Each code can be used when a definitive diagnosis has not been established.

Accurate Reporting of Diagnosis Codes and Symptoms and Signs Official ICD-9-CM Coding Guideline: For accurate reporting of ICD-9-CM diagnosis, the documentation should describe the patient’s condition, using terminology which includes specific diagnoses as well as symptoms, problems, or reasons for the encounter. There are ICD-9-CM codes to describe all of these. (See Appendix A, Section IV, C.) Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting when a diagnosis has not been established (i.e., confirmed) by the provider. Chapter 16, Symptoms, Signs, and Ill-defined conditions (codes 780.0-799.9) contain many, but not all codes from symptoms. (See Appendix A, Section IV, E.) EXAMPLE: Mary Banks presents with low back pain. She was working in her garden when she bent down and felt a “pop” in her lower back next to her spine. She is in severe pain, which radiates into her legs. She has had previous back pain, and her physician suspects that she may have a protruding disc. He orders X-rays and magnetic resonance imaging. At the conclusion of this encounter, the symptom of back pain should be coded because the suspected protruding disc has not been confirmed.

Observation Stay The following guideline should be followed when selecting a first-listed diagnosis for patients who are admitted for observation for a medical condition.

Official ICD-9-CM Coding Guideline: When a patient is admitted for observation for a medical condition, assign a code for the medical condition as the firstlisted diagnosis. When a patient presents for outpatient surgery and develops complications requiring admission to observation, code the reason for the surgery as the first-reported diagnosis (reason for the encounter), followed by codes for the complications as secondary diagnoses. (See Appendix A, Section IV, A2.)

Encounters for Circumstances Other Than a Disease or Injury It is common in physicians’ offices for patients to seek care, such as preventative medical care, when a disease or injury is not present. For these encounters, ICD-9-CM provides a supplementary classification known as the V codes, which will be further discussed later in this book. Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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Official ICD-9-CM Coding Guideline: ICD-9-CM provides codes to deal with encounters for circumstances other than a disease or injury. The Supplementary Classification of Factors Influencing Health Status and Contact with Health Services (V01.0−V91.99) is provided to deal with occasions when circumstances other than a disease or injury are recorded as diagnoses or problems. See Section I. C. 18 for information on V codes. (See Appendix A, Section IV, F.) EXAMPLE: Tim Smith and his wife, Sue, have been trying unsuccessfully to conceive a child. Sue has been seen by a physician, and it has been determined that she should be able to conceive. Tim is now presenting to undergo sperm count testing for fertility. This encounter would be coded by using code V26.21, Fertility testing.

Sequencing and Multiple Codes for Outpatient and Physician Office Visits For outpatient and physician office visits, the code that is listed first for coding and reporting purposes is the reason for the encounter.

Official ICD-9-CM Coding Guideline: List first the ICD-9-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided. List additional codes that describe any coexisting conditions. In some cases the first-listed diagnosis may be a symptom when a diagnosis has not been established (confirmed) by the physician. (See Appendix A, Section IV, H.)

EXAMPLE: Edward Smith presented to his primary care provider because of an upper respiratory infection and a reoccurrence of migraine headaches, which he experienced yesterday. Currently he does not have a headache, but he would like his prescription renewed for his medication for migraines. The upper respiratory infection is listed as the first diagnosis, followed by the migraine headaches.

Official ICD-9-CM Coding Guideline: Chronic disease treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s). (See Appendix A, Section IV, J.) Code all documented conditions that coexist at the time of the encounter/visit and that require or affect patient care, treatment, or management. Do not code conditions that were previously treated and no longer exist. However, history codes (V10−V19) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment. (See Appendix A, Section IV, K.)

EXAMPLE: Pam Lord is diabetic and is being seen for gastritis. Her blood sugar was taken, and she was given Prevacid for the gastritis. Gastritis would be listed first, followed by the code for diabetes mellitus. Diabetes is a chronic condition that should be coded because the patient received treatment for the condition on this visit as well as for the gastritis.

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Encounters for Diagnostic Services The Official Guidelines provide the following instruction for coding encounters when a diagnostic service is the only service provided during the encounter:

Official ICD-9-CM Coding Guideline: For patients receiving diagnostic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for the encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses. For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis(es) documented in the interpretation. Do not code related signs and symptoms as additional diagnoses. (See Appendix A, Section IV, L.) EXAMPLE: Gretchen Rose has noticed a lump in her left breast. She presents to her primary care provider to discuss this. Her mother had breast cancer at the age of 54 and died. The provider orders a mammogram. The mass in the breast would be listed first, code 611.72, as the reason for the visit, followed by a code for family history of malignant neoplasm of breast, V16.3. EXAMPLE: The mammogram for Gretchen Rose revealed a mass in the breast and she had a biopsy on 9/10/XX. At the time of coding for the biopsy, the physician has recorded a diagnosis of primary carcinoma of the breast, lower-inner quadrant. This would be coded by using code 174.3.

Encounters for Therapeutic Services The following guideline is provided for coding encounters for therapeutic services:

Official ICD-9-CM Coding Guideline: For patients receiving therapeutic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses. The only exception to this rule is that when the primary reason for the admission/encounter is chemotherapy, radiation therapy, or rehabilitation, the appropriate V code for the service is listed first, and the diagnosis or problem for which the service is being performed listed second. (See Appendix A, Section IV, M.) EXAMPLE: Penny Black, a dialysis patient, is seen in the clinic for a therapeutic injection of Aranesp for anemia due to end-stage renal disease. Codes 585, Chronic renal failure, and 285.21, Anemia in end-stage renal disease, are assigned for this case because they are the reasons for the therapeutic service.

Preoperative Evaluations At times, before surgery, surgeons require patients to obtain preoperative clearance from their primary care provider.

Official ICD-9-CM Coding Guideline: For patients receiving preoperative evaluations only, sequence first a code from category V72.8, Other specified examinations, to describe the preop consultations. Assign a code for the condition to describe the reason for the surgery as an additional diagnosis. Code also any findings related to the preop evaluation. (See Appendix A, Section IV, N.)

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Ambulatory/Outpatient Surgery The following guidelines give direction to the coder when ambulatory/outpatient surgery episodes of care are coded:

Official ICD-9-CM Coding Guideline: For ambulatory surgery, code the diagnosis for which the surgery was performed. If the postoperative diagnosis is known to be different from the preoperative diagnosis at the time the diagnosis is confirmed, select the postoperative diagnosis for coding since it is the most definitive. (See Appendix A, Section IV, O.) When a patient presents for outpatient surgery, code the reason for the surgery as the first-listed diagnosis (reason for the encounter), even if the surgery is not performed due to a contraindication. (See Appendix A, Section IV, A, 1.)

EXAMPLE: Bill Best is admitted for ambulatory surgery for an umbilical hernia. On the operative report, the physician records the following: preoperative diagnosis, umbilical hernia; postoperative diagnosis, umbilical hernia with gangrene. Because the postoperative diagnosis was available at the time of coding, the postoperative diagnosis of umbilical hernia with gangrene would be coded as code 551.1, because it represents the more definitive diagnosis.

Routine Outpatient Prenatal Visits During pregnancy, many prenatal visits will occur. For routine visits during the pregnancy when no other abnormal condition exists, the following guideline should be used:

Official ICD-9-CM Coding Guideline: For routine outpatient prenatal visits when no complications are present, codes V22.0, Supervision of normal first pregnancy, or V22.1, Supervision of other normal pregnancy, should be used as the principal diagnoses. These codes should not be used in conjunction with chapter 11 codes. (See Appendix A, Section I, V, P.)

EXAMPLE: Sherrie Gage presents to her obstetrician for her third prenatal visit during her first pregnancy. He completes the exam and finds her pregnancy to be progressing normally. This encounter is coded during code V22.0, Supervision of normal first pregnancy.

Appendix I of the ICD-9-CM Official Guidelines for Coding and Reporting—Present on Admission Reporting Guidelines Effective October 1, 2007, CMS required that present on admission (POA) indicators be assigned for all diagnoses and external causes of injury codes for inpatient acute care discharges as part of changes to the DRG reimbursement system. The POA indicator is used to report whether the diagnosis and/or external cause of the injury was present at the time of admission. Appendix I of the Official Guidelines states that “present on admission is defined as present at the time the order for inpatient admission occurs—conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered as present on admission.” POA indicators are assigned to principal and secondary diagnoses and the external cause of injury codes, according to this definition. It should be noted that the POA guidelines provide guidance to coders on how to apply the POA indicators to the codes selected for the discharge. The POA indicator is assigned after coders have

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Introduction to Coding

selected the principal and secondary diagnosis(es) for the case. When selecting codes, the coder is to be guided by Sections I to III of the ICD-9-CM Official Guidelines for Coding and Reporting. Do not confuse the purpose of Appendix I of the Guidelines. To learn more about how to select POA indicators, read the Present on Admission Reporting Guidelines in Appendix A of this textbook.

Internet Links The ICD-9-CM Official Guidelines for Coding and Reporting can be found online at http://www.cdc.gov/nchs/data/icd9/icdguide10.pdf.

Summary • The ICD-9-CM Official Guidelines for Coding and Reporting were developed by the Cooperating Parties for ICD-9-CM. • The Cooperating Parties for ICD-9-CM include the American Hospital Association, American Health Information Association, Centers for Medicare and Medicaid Services, and the National Center for Health Statistics. • There are four sections of the ICD-9-CM Official Guidelines for Coding and Reporting. • Section I contains the ICD-9-CM Conventions, General Coding Guidelines, and Chapter-Specific Guidelines. • Section II describes the Selection of Principal Diagnosis(es) for Inpatient, Short-Term, Acute Care, and Long-Term Care Hospital Records. • Section III describes the Reporting of Additional Diagnoses for Inpatient, Short-Term, Acute Care, and Long-Term Care Hospital Records. • Section IV describes the Diagnostic Coding and Reporting Guidelines for Outpatient Services. • Appendix A, of the textbook, provides a complete listing of all the ICD-9-CM Official Guidelines for Coding and Reporting.

Chapter Review True/False: Indicate whether each statement is true (T) or false (F). 1.

The ICD-9-CM Official Guidelines for Coding and Reporting were developed by the American Health Information Management Association.

2.

For outpatient and physician office visits, the code that is listed first for coding and reporting purposes is the reason for the encounter.

3.

Codes that describe symptoms and signs are acceptable for coding when a definitive diagnosis has not been established in a physician’s office.

4.

If signs and symptoms exist that are not routinely associated with a disease process, the signs and symptoms should not be coded.

5.

Late effect codes should be used only within six months after the initial injury or disease.

6.

The principal diagnosis is defined as “that condition established after study to be chiefly responsible for occasioning the outpatient visit of the patient to the hospital for care.”

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7.

If the diagnosis documented at the time of discharge is qualified as “probable” or “suspected,” do not code the condition.

8.

Codes from chapter 16 of ICD-9-CM, “Symptoms, Signs, and Ill-Defined Conditions,” are not to be used as a principal diagnosis when a related definitive diagnosis has been established.

9.

A patient is admitted because of severe abdominal pain. After diagnostic testing, it was determined that the patient has appendicitis. The abdominal pain is the principal diagnosis.

10.

In a physician’s office, a chronic disease treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition.

Fill-in-the-Blank: Enter the appropriate term(s) to complete each statement. 11.

is the residual effect (condition produced) after the acute A phase of an illness or injury has terminated.

12.

For ambulatory surgery, if the postoperative diagnosis is known to be different from the preoperative diagnosis at the time the diagnosis is confirmed, select the diagnosis for coding.

13. In the

setting, the definition of principal diagnosis does not apply.

14.

For outpatient and physician office visits, the code that is listed first for coding and reporting purposes . is the

15.

Rule out conditions are not coded in the

setting.

16. When the final report is available at the time of coding for outpatient diagnostic tests, code the diagnosis(es) documented in the interpretation. 17. Abnormal findings are not coded and reported for unless the physician documents the significance of the findings. 18. In the outpatient setting, the term

is used in lieu of principal diagnosis.

19. In most cases when coding late effects, two codes are required, with the sequenced first followed by the cause of the late effect. 20. When coding a late effect, a second code is not needed when medical documentation does not identify the . Short Answer: Briefly answer each of the following. 21. Explain the ICD-9-CM Official Guideline for coding two or more interrelated conditions that equally meet the definition for principal diagnosis.

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22. Discuss how to code a diagnosis recorded as “suspected” in both an inpatient and an outpatient record.

23. List the Cooperating Parties that developed the ICD-9-CM Official Coding Guidelines.

24. List the sections of the ICD-9-CM Official Guidelines for Coding and Reporting.

25. Define the term present on admission as it applies to POA indicators.

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Appendix C: Partial Answer Keys to Textbook Exercises

CHAPTER 1 Chapter Review True/False: Indicate whether each statement is true (T) or false (F). 1. F 3. F 5. T Fill-in-the-Blank: Enter the appropriate term(s) to complete the statement. 7. World Health Organization 9. the National Center for Health Statistics Short Answer: Define each abbreviation and acronym listed. 11. American Health Information Management Association 13. Certified Professional Coder, Hospital-Based 15. Certified Professional Coder 17. Registered Medical Assistant 19. Certified Coding Specialist

CHAPTER 2 Chapter Review True/False: Indicate whether each statement is true (T) or false (F). 1. F 3. T 5. T Fill-in-the-Blank: Enter the appropriate term(s) to complete the statement. 7. Alphabetic Index 9. 17, Injury and Poisoning

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Appendix C

Partial Answer Keys to Textbook Exercises

Short Answer: Briefly respond to each question. 11. Volume 1, Tabular List of Diseases and Injuries, contains reference information regarding the code selected. Volume 2, Alphabetic Index, contains the alphabetic listing of diseases and injuries classified in ICD-9-CM. Volume 3, Tabular List and Alphabetic Index of Procedures, contains the alphabetic and numerical listing of procedure codes used for facility reporting. 13. This chapter includes symptoms, signs, abnormal results of laboratory tests and investigative procedures, and ill-defined conditions. 15. E codes classify environmental events, circumstances, and other conditions as the cause of an injury and adverse effect.

CHAPTER 3 Chapter Review True/False: Indicate whether each statement is true (T) or false (F). 1. T 3. T 5. T Fill-in-the-Blank: Enter the appropriate term(s) to complete the statement. 7. assault 9. four Short Answer: Complete each exercise by referencing an ICD-9-CM code book. 11. Use volume 1, Tabular List of Disease and Injuries, to complete the following list. Chapter Title

First Section in Chapter

Code Range of Section

Diseases of Circulatory System

Acute Rheumatic Fever

390–392

Diseases of Genitourinary System

Nephritis, Nephrotic Syndrome, and Nephrosis

580–589

Neoplasms

Malignant Neoplasm of Lip, Oral Cavity, and Pharynx

140–149

Mental Disorders

Psychoses

290–299

Infectious and Parasitic Diseases

Intestinal Infectious Disease

001–009

Symptoms, Signs, and Ill-Defined Conditions

Symptoms

780–789

Diseases of Respiratory System

Acute Respiratory Infections

460–466

Diseases of the Nervous System and Sense Organs

Inflammatory Diseases of the Central Nervous System

320–326

Diseases of Musculoskeletal and Connective Tissue

Arthropathies and Related Disorders

710–719

CHAPTER 4 Chapter Review True/False: Indicate whether each statement is true (T) or false (F). 1. F 3. T

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Partial Answer Keys to Textbook Exercises

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5. T 7. F 9. F Short Answer: For each diagnostic or procedural statement listed, identify the main term that would be used in the Alphabetic Index of ICD-9-CM. 11. Angina 13. Punctured 15. Excision 17. Pain 19. Neoplasm 21. Release 23. Bypass 25. Reconstruction 27. Synostosis 29. Lordosis Short Answer: Briefly respond to the following. 31. Locate the main term in volume 2, the Alphabetic Index. Scan the main term entry for any instructional notations. Identify any terms that modify the main term. Follow any cross-reference notations. Always verify the code in volume 1, the Tabular List. Follow any instructional terms. Select the code. 33. Coders must reference both the Alphabetic Index and the Tabular List to review all the coding conventions that are displayed in the two volumes to select the most accurate code. 35. Instructional notations lead the coder to correctly assign a diagnosis code.

CHAPTER 5 Chapter Review True/False: Indicate whether each statement is true (T) or false (F). 1. F 3. T 5. F 7. F 9. F Fill-in-the-Blank: Enter the appropriate term(s) to complete each statement. 11. late effect 13. outpatient or physician’s office

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.

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Appendix C

Partial Answer Keys to Textbook Exercises

15. outpatient or physician’s office 17. inpatients 19. residual condition Short Answer: Briefly answer each of the following. 21. When two or more interrelated conditions equally meet the definition for principal diagnosis, the guidelines state that any one of the diagnoses may be sequenced first. 23. American Hospital Association American Health Information Association Centers for Medicare and Medicaid Services (CMS) National Center for Health Statistics (NCHS) 25. The POA indicator is used to report whether the diagnosis and/or external cause of the injury was present at the time of admission.

This page contains answers for this chapter only

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.